- 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
- $390.68 / $494.23 / $527.34
| Professional | | $390.68 | $494.23 | $527.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.65 / $775.06 / $930.08
| Professional | | $669.65 | $775.06 | $930.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.27 / $826.25 / $3,857.00
| Professional | | $684.27 | $826.25 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.23 / $663.05 / $775.06
| Professional | | $486.23 | $663.05 | $775.06 |
- 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
- $557.72 / $745.64 / $985.73
| Professional | | $557.72 | $745.64 | $985.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.38 / $1,958.52 / $5,287.00
| Professional | | $528.38 | $1,958.52 | $5,287.00 |