- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.03 / $2,747.00 / $4,456.00
| Facility | | $1,324.03 | $2,747.00 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.78 / $157.51 / $176.86
| Professional | | $146.78 | $157.51 | $176.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.09 / $144.09 / $194.35
| Professional | | $144.09 | $144.09 | $194.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.84 / $416.33 / $2,540.00
| Professional | | $361.84 | $416.33 | $2,540.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.80 / $138.32 / $161.38
| Professional | | $126.80 | $138.32 | $161.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.58 / $152.58 / $193.31
| Professional | | $117.58 | $152.58 | $193.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.95 / $2,582.96 / $6,124.00
| Professional | | $164.95 | $2,582.96 | $6,124.00 |