- 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
- $528.94 / $632.40 / $987.92
| Professional | | $528.94 | $632.40 | $987.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.80 / $770.60 / $924.72
| Professional | | $665.80 | $770.60 | $924.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.68 / $898.51 / $4,765.00
| Professional | | $787.68 | $898.51 | $4,765.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.13 / $739.78 / $863.07
| Professional | | $678.13 | $739.78 | $863.07 |
- 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
- $565.85 / $744.81 / $982.11
| Professional | | $565.85 | $744.81 | $982.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.16 / $2,040.00 / $5,304.00
| Professional | | $590.16 | $2,040.00 | $5,304.00 |