- 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
- $247.88 / $293.91 / $587.59
| Professional | | $247.88 | $293.91 | $587.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.11 / $452.04 / $542.45
| Professional | | $357.11 | $452.04 | $542.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.06 / $482.42 / $2,077.00
| Professional | | $72.06 | $482.42 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.09 / $404.65 / $470.12
| Professional | | $356.09 | $404.65 | $470.12 |
- 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
- $314.76 / $450.89 / $540.02
| Professional | | $314.76 | $450.89 | $540.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.12 / $1,958.52 / $5,287.00
| Professional | | $348.12 | $1,958.52 | $5,287.00 |