- 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
- $362.71 / $362.71 / $396.13
| Professional | | $362.71 | $362.71 | $396.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.94 / $591.95 / $710.34
| Professional | | $455.94 | $591.95 | $710.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.30 / $658.74 / $2,077.00
| Professional | | $586.30 | $658.74 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.17 / $532.01 / $615.63
| Professional | | $468.17 | $532.01 | $615.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.52 / $591.95 / $695.25
| Professional | | $427.52 | $591.95 | $695.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.42 / $448.81 / $603.35
| Professional | | $75.42 | $448.81 | $603.35 |