- 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
- $383.71 / $383.71 / $383.71
| Professional | | $383.71 | $383.71 | $383.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.16 / $486.53 / $583.83
| Professional | | $373.16 | $486.53 | $583.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.79 / $586.25 / $2,077.00
| Professional | | $521.79 | $586.25 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.14 / $467.06 / $544.91
| Professional | | $428.14 | $467.06 | $544.91 |
- 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
- $397.00 / $486.53 / $572.48
| Professional | | $397.00 | $486.53 | $572.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.59 / $2,040.00 / $5,304.00
| Professional | | $458.59 | $2,040.00 | $5,304.00 |