- 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
- $194.84 / $206.50 / $235.34
| Professional | | $194.84 | $206.50 | $235.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.65 / $172.50 / $207.00
| Professional | | $133.65 | $172.50 | $207.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.62 / $317.52 / $2,077.00
| Professional | | $282.62 | $317.52 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.80 / $165.60 / $193.20
| Professional | | $151.80 | $165.60 | $193.20 |
- 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
- $140.76 / $172.50 / $235.95
| Professional | | $140.76 | $172.50 | $235.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.45 / $2,040.00 / $5,304.00
| Professional | | $198.45 | $2,040.00 | $5,304.00 |