- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.03 / $2,747.00 / $4,456.00
| Facility | | $1,324.03 | $2,747.00 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.36 / $382.56 / $1,281.70
| Professional | | $245.36 | $382.56 | $1,281.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.40 / $516.42 / $619.71
| Professional | | $421.40 | $516.42 | $619.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.29 / $490.69 / $655.76
| Professional | | $396.29 | $490.69 | $655.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.98 / $413.14 / $516.42
| Professional | | $274.98 | $413.14 | $516.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.40 / $516.42 / $1,004.38
| Professional | | $421.40 | $516.42 | $1,004.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.45 / $311.60 / $495.74
| Professional | | $71.45 | $311.60 | $495.74 |