- 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
- $468.68 / $468.68 / $854.49
| Professional | | $468.68 | $468.68 | $854.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.41 / $664.40 / $797.28
| Professional | | $519.41 | $664.40 | $797.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.50 / $788.15 / $3,857.00
| Professional | | $701.50 | $788.15 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.66 / $637.82 / $744.13
| Professional | | $584.66 | $637.82 | $744.13 |
- 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
- $491.49 / $664.40 / $794.99
| Professional | | $491.49 | $664.40 | $794.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.24 / $544.13 / $817.44
| Professional | | $90.24 | $544.13 | $817.44 |