- 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
- $202.25 / $202.25 / $202.25
| Professional | | $202.25 | $202.25 | $202.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.53 / $234.53 / $260.01
| Professional | | $234.53 | $234.53 | $260.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.16 / $341.90 / $7,637.00
| Professional | | $297.16 | $341.90 | $7,637.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.38 / $225.14 / $262.67
| Professional | | $206.38 | $225.14 | $262.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.37 / $262.35 / $335.01
| Professional | | $191.37 | $262.35 | $335.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.43 / $2,582.96 / $6,124.00
| Professional | | $268.43 | $2,582.96 | $6,124.00 |