- 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
- $285.56 / $415.25 / $538.30
| Professional | | $285.56 | $415.25 | $538.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.48 / $635.54 / $762.66
| Professional | | $495.48 | $635.54 | $762.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.62 / $619.17 / $788.66
| Professional | | $523.62 | $619.17 | $788.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.86 / $538.95 / $635.54
| Professional | | $372.86 | $538.95 | $635.54 |
- 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
- $501.69 / $635.54 / $820.73
| Professional | | $501.69 | $635.54 | $820.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.94 / $1,958.52 / $5,287.00
| Professional | | $427.94 | $1,958.52 | $5,287.00 |