- 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
- $298.00 / $493.00 / $2,018.84
| Professional | | $298.00 | $493.00 | $2,018.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.78 / $727.43 / $872.91
| Professional | | $574.78 | $727.43 | $872.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.20 / $626.42 / $915.14
| Professional | | $528.20 | $626.42 | $915.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.85 / $616.86 / $727.43
| Professional | | $385.85 | $616.86 | $727.43 |
- 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
- $593.58 / $727.43 / $895.28
| Professional | | $593.58 | $727.43 | $895.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.59 / $1,958.52 / $5,287.00
| Professional | | $449.59 | $1,958.52 | $5,287.00 |