- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.26 / $1,878.40 / $4,456.00
| Facility | | $533.26 | $1,878.40 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.55 / $608.97 / $2,207.34
| Professional | | $499.55 | $608.97 | $2,207.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.92 / $716.83 / $860.19
| Professional | | $584.92 | $716.83 | $860.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.41 / $806.73 / $3,857.00
| Professional | | $70.41 | $806.73 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.55 / $672.23 / $752.89
| Professional | | $591.55 | $672.23 | $752.89 |
- 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
- $584.92 / $716.83 / $884.61
| Professional | | $584.92 | $716.83 | $884.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.16 / $758.58 / $5,309.00
| Professional | | $361.16 | $758.58 | $5,309.00 |