- 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
- $427.92 / $427.92 / $427.92
| Professional | | $427.92 | $427.92 | $427.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.59 / $457.59 / $540.79
| Professional | | $457.59 | $457.59 | $540.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.16 / $654.86 / $10,901.00
| Professional | | $569.16 | $654.86 | $10,901.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.68 / $439.28 / $512.50
| Professional | | $402.68 | $439.28 | $512.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.39 / $498.61 / $656.81
| Professional | | $373.39 | $498.61 | $656.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.96 / $2,650.00 / $6,124.00
| Professional | | $513.96 | $2,650.00 | $6,124.00 |