- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $1,000.00 / $2,884.03
| Facility | | $467.74 | $1,000.00 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $269.15 / $407.38
| Professional | | $229.09 | $269.15 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $323.59 / $426.58
| Professional | | $302.00 | $323.59 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $457.09 / $2,570.40
| Professional | | $389.05 | $457.09 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $389.05 / $489.78
| Professional | | $316.23 | $389.05 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $323.59 / $416.87
| Professional | | $218.78 | $323.59 | $416.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $302.00 / $407.38
| Professional | | $51.29 | $302.00 | $407.38 |