- 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
- $272.11 / $285.48 / $285.48
| Professional | | $272.11 | $285.48 | $285.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.87 / $317.95 / $328.63
| Professional | | $262.87 | $317.95 | $328.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.68 / $439.16 / $6,874.20
| Professional | | $381.68 | $439.16 | $6,874.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.81 / $305.24 / $356.12
| Professional | | $279.81 | $305.24 | $356.12 |
- 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
- $259.45 / $325.13 / $421.25
| Professional | | $259.45 | $325.13 | $421.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.75 / $2,582.96 / $6,124.00
| Professional | | $343.75 | $2,582.96 | $6,124.00 |