- 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
- $280.14 / $460.43 / $2,161.00
| Professional | | $280.14 | $460.43 | $2,161.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.23 / $691.75 / $830.10
| Professional | | $551.23 | $691.75 | $830.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.10 / $612.89 / $819.61
| Professional | | $521.10 | $612.89 | $819.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.07 / $586.60 / $691.75
| Professional | | $374.07 | $586.60 | $691.75 |
- 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
- $527.07 / $691.75 / $866.30
| Professional | | $527.07 | $691.75 | $866.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.75 / $1,958.52 / $5,287.00
| Professional | | $403.75 | $1,958.52 | $5,287.00 |