- 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
- $397.71 / $397.71 / $607.94
| Professional | | $397.71 | $397.71 | $607.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.91 / $685.09 / $822.11
| Professional | | $591.91 | $685.09 | $822.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.28 / $659.61 / $3,857.00
| Professional | | $546.28 | $659.61 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.60 / $548.07 / $685.09
| Professional | | $395.60 | $548.07 | $685.09 |
- 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
- $482.50 / $656.60 / $866.39
| Professional | | $482.50 | $656.60 | $866.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.49 / $1,958.52 / $5,287.00
| Professional | | $431.49 | $1,958.52 | $5,287.00 |