- 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
- $190.04 / $204.05 / $229.52
| Professional | | $190.04 | $204.05 | $229.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.94 / $258.14 / $271.00
| Professional | | $204.94 | $258.14 | $271.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.32 / $326.81 / $3,935.00
| Professional | | $284.32 | $326.81 | $3,935.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.55 / $260.16 / $303.52
| Professional | | $204.55 | $260.16 | $303.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.14 / $271.00 / $337.41
| Professional | | $221.14 | $271.00 | $337.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.23 / $1,958.52 / $5,287.00
| Professional | | $203.23 | $1,958.52 | $5,287.00 |