- 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
- $236.11 / $332.02 / $643.91
| Professional | | $236.11 | $332.02 | $643.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.90 / $496.49 / $595.79
| Professional | | $390.90 | $496.49 | $595.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.89 / $484.54 / $615.16
| Professional | | $415.89 | $484.54 | $615.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.87 / $421.02 / $496.49
| Professional | | $295.87 | $421.02 | $496.49 |
- 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
- $389.73 / $496.49 / $661.80
| Professional | | $389.73 | $496.49 | $661.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.20 / $1,958.52 / $5,287.00
| Professional | | $348.20 | $1,958.52 | $5,287.00 |