- 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
- $503.24 / $524.39 / $524.39
| Professional | | $503.24 | $524.39 | $524.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.30 / $609.61 / $609.61
| Professional | | $483.30 | $609.61 | $609.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.83 / $768.31 / $906.61
| Professional | | $683.83 | $768.31 | $906.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.46 / $585.23 / $682.77
| Professional | | $536.46 | $585.23 | $682.77 |
- 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
- $497.44 / $609.61 / $780.75
| Professional | | $497.44 | $609.61 | $780.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.59 / $2,000.00 / $5,304.00
| Professional | | $449.59 | $2,000.00 | $5,304.00 |