- 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
- $439.67 / $463.27 / $463.27
| Professional | | $439.67 | $463.27 | $463.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.89 / $534.59 / $534.59
| Professional | | $421.89 | $534.59 | $534.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.30 / $685.70 / $809.13
| Professional | | $610.30 | $685.70 | $809.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.44 / $513.20 / $598.74
| Professional | | $470.44 | $513.20 | $598.74 |
- 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
- $436.22 / $534.59 / $682.50
| Professional | | $436.22 | $534.59 | $682.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.21 / $2,000.00 / $5,304.00
| Professional | | $429.21 | $2,000.00 | $5,304.00 |