- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.00 / $2,747.00 / $3,883.00
| Facility | | $1,486.00 | $2,747.00 | $3,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.83 / $606.83 / $606.83
| Professional | | $606.83 | $606.83 | $606.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.32 / $831.88 / $998.25
| Professional | | $660.32 | $831.88 | $998.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.80 / $989.60 / $5,851.00
| Professional | | $880.80 | $989.60 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.05 / $798.60 / $931.70
| Professional | | $732.05 | $798.60 | $931.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.81 / $831.88 / $1,061.75
| Professional | | $678.81 | $831.88 | $1,061.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $601.90 / $906.39
| Professional | | $29.27 | $601.90 | $906.39 |