- 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
- $387.00 / $485.39 / $847.28
| Professional | | $387.00 | $485.39 | $847.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.69 / $603.25 / $666.25
| Professional | | $496.69 | $603.25 | $666.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $659.04 / $759.10 / $853.13
| Professional | | $659.04 | $759.10 | $853.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.65 / $586.29 / $746.20
| Professional | | $454.65 | $586.29 | $746.20 |
- 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
- $543.66 / $666.25 / $850.95
| Professional | | $543.66 | $666.25 | $850.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.10 / $2,000.00 / $5,304.00
| Professional | | $488.10 | $2,000.00 | $5,304.00 |