- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.88 / $2,747.00 / $3,883.00
| Facility | | $1,157.88 | $2,747.00 | $3,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.74 / $342.74 / $625.73
| Professional | | $342.74 | $342.74 | $625.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.41 / $976.35 / $1,171.61
| Professional | | $761.41 | $976.35 | $1,171.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.29 / $720.24 / $1,002.24
| Professional | | $625.29 | $720.24 | $1,002.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.80 / $827.94 / $976.35
| Professional | | $535.80 | $827.94 | $976.35 |
- 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
- $697.73 / $976.35 / $1,221.86
| Professional | | $697.73 | $976.35 | $1,221.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.32 / $1,958.52 / $5,287.00
| Professional | | $569.32 | $1,958.52 | $5,287.00 |