- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $466.80 / $600.90 / $2,898.00
| Facility | | $466.80 | $600.90 | $2,898.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.43 / $226.50 / $243.47
| Professional | | $206.43 | $226.50 | $243.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.10 / $393.83 / $472.59
| Professional | | $307.10 | $393.83 | $472.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.68 / $437.82 / $2,077.00
| Professional | | $389.68 | $437.82 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.81 / $354.33 / $409.58
| Professional | | $311.81 | $354.33 | $409.58 |
- 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
- $282.48 / $390.72 / $461.79
| Professional | | $282.48 | $390.72 | $461.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.03 / $300.39 / $408.22
| Professional | | $51.03 | $300.39 | $408.22 |