- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.03 / $2,747.00 / $4,456.00
| Facility | | $1,324.03 | $2,747.00 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.24 / $505.04 / $505.04
| Professional | | $428.24 | $505.04 | $505.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.79 / $693.93 / $693.93
| Professional | | $548.79 | $693.93 | $693.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.39 / $848.43 / $4,334.00
| Professional | | $737.39 | $848.43 | $4,334.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.65 / $666.17 / $777.20
| Professional | | $610.65 | $666.17 | $777.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.24 / $693.93 / $868.82
| Professional | | $566.24 | $693.93 | $868.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.83 / $2,582.96 / $6,124.00
| Professional | | $675.83 | $2,582.96 | $6,124.00 |