- 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
- $560.05 / $560.05 / $560.05
| Professional | | $560.05 | $560.05 | $560.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.40 / $640.51 / $768.62
| Professional | | $553.40 | $640.51 | $768.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.44 / $746.51 / $2,540.00
| Professional | | $664.44 | $746.51 | $2,540.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.65 / $614.89 / $717.37
| Professional | | $563.65 | $614.89 | $717.37 |
- 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
- $466.53 / $585.19 / $647.55
| Professional | | $466.53 | $585.19 | $647.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.03 / $2,040.00 / $5,304.00
| Professional | | $515.03 | $2,040.00 | $5,304.00 |