- 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
- $178.44 / $267.27 / $1,262.55
| Professional | | $178.44 | $267.27 | $1,262.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.36 / $392.60 / $471.12
| Professional | | $320.36 | $392.60 | $471.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.51 / $485.35 / $5,851.00
| Professional | | $429.51 | $485.35 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.01 / $314.08 / $392.60
| Professional | | $240.01 | $314.08 | $392.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.00 / $1,106.00 / $1,106.00
| Facility | | $1,106.00 | $1,106.00 | $1,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.36 / $392.60 / $506.94
| Professional | | $320.36 | $392.60 | $506.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.46 / $370.86 / $4,597.00
| Professional | | $53.46 | $370.86 | $4,597.00 |