- 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
- $371.04 / $371.04 / $371.04
| Professional | | $371.04 | $371.04 | $371.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.92 / $463.92 / $515.59
| Professional | | $463.92 | $463.92 | $515.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.03 / $595.38 / $736.03
| Professional | | $544.03 | $595.38 | $736.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.72 / $494.96 / $577.46
| Professional | | $453.72 | $494.96 | $577.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.72 / $515.59 / $648.80
| Professional | | $420.72 | $515.59 | $648.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.85 / $2,040.00 / $5,304.00
| Professional | | $487.85 | $2,040.00 | $5,304.00 |