- 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
- $325.16 / $453.42 / $621.60
| Professional | | $325.16 | $453.42 | $621.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.14 / $703.86 / $844.64
| Professional | | $608.14 | $703.86 | $844.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.21 / $715.08 / $3,857.00
| Professional | | $592.21 | $715.08 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.80 / $591.54 / $703.86
| Professional | | $433.80 | $591.54 | $703.86 |
- 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
- $491.87 / $670.74 / $888.33
| Professional | | $491.87 | $670.74 | $888.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.94 / $1,958.52 / $5,287.00
| Professional | | $455.94 | $1,958.52 | $5,287.00 |