- 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
- $322.25 / $455.77 / $598.01
| Professional | | $322.25 | $455.77 | $598.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.88 / $694.50 / $833.40
| Professional | | $537.88 | $694.50 | $833.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.15 / $674.65 / $853.22
| Professional | | $576.15 | $674.65 | $853.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.11 / $588.94 / $694.50
| Professional | | $414.11 | $588.94 | $694.50 |
- 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
- $539.13 / $692.91 / $881.75
| Professional | | $539.13 | $692.91 | $881.75 |
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 |