- 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
- $605.91 / $605.91 / $605.91
| Professional | | $605.91 | $605.91 | $605.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.35 / $797.00 / $956.40
| Professional | | $650.35 | $797.00 | $956.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.35 / $920.76 / $1,115.43
| Professional | | $841.35 | $920.76 | $1,115.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.36 / $765.12 / $892.64
| Professional | | $701.36 | $765.12 | $892.64 |
- 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
- $748.65 / $797.00 / $994.29
| Professional | | $748.65 | $797.00 | $994.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.17 / $2,040.00 / $5,304.00
| Professional | | $735.17 | $2,040.00 | $5,304.00 |