- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.03 / $4,456.00 / $4,456.00
| Facility | | $1,324.03 | $4,456.00 | $4,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.52 / $323.42 / $445.96
| Professional | | $205.52 | $323.42 | $445.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.74 / $351.08 / $454.14
| Professional | | $243.74 | $351.08 | $454.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.41 / $380.64 / $551.10
| Professional | | $307.41 | $380.64 | $551.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.81 / $399.64 / $508.63
| Professional | | $212.81 | $399.64 | $508.63 |
- 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
- $370.58 / $454.14 / $564.80
| Professional | | $370.58 | $454.14 | $564.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.27 / $2,500.00 / $6,063.00
| Professional | | $260.27 | $2,500.00 | $6,063.00 |