- 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
- $439.30 / $439.30 / $512.24
| Professional | | $439.30 | $439.30 | $512.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.90 / $584.38 / $701.25
| Professional | | $504.90 | $584.38 | $701.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.95 / $690.29 / $4,582.80
| Professional | | $599.95 | $690.29 | $4,582.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.25 / $514.25 / $600.35
| Professional | | $440.25 | $514.25 | $600.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.00 / $1,689.00 / $1,689.00
| Facility | | $1,689.00 | $1,689.00 | $1,689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.93 / $562.55 / $744.36
| Professional | | $422.93 | $562.55 | $744.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.68 / $1,958.52 / $5,287.00
| Professional | | $429.68 | $1,958.52 | $5,287.00 |