- 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
- $637.04 / $637.04 / $637.04
| Professional | | $637.04 | $637.04 | $637.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.54 / $725.16 / $870.20
| Professional | | $626.54 | $725.16 | $870.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.92 / $825.09 / $999.53
| Professional | | $753.92 | $825.09 | $999.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.14 / $696.16 / $812.18
| Professional | | $638.14 | $696.16 | $812.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $532.08 / $701.95 / $925.59
| Professional | | $532.08 | $701.95 | $925.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.36 / $2,582.96 / $6,124.00
| Professional | | $577.36 | $2,582.96 | $6,124.00 |