- 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
- $459.59 / $459.59 / $625.35
| Professional | | $459.59 | $459.59 | $625.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.71 / $704.53 / $845.43
| Professional | | $608.71 | $704.53 | $845.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.64 / $757.03 / $3,857.00
| Professional | | $643.64 | $757.03 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.22 / $619.98 / $704.53
| Professional | | $464.22 | $619.98 | $704.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.70 / $674.90 / $895.88
| Professional | | $501.70 | $674.90 | $895.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.49 / $1,958.52 / $5,287.00
| Professional | | $468.49 | $1,958.52 | $5,287.00 |