- 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
- $202.24 / $264.64 / $1,093.93
| Professional | | $202.24 | $264.64 | $1,093.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.44 / $320.20 / $329.14
| Professional | | $241.44 | $320.20 | $329.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.64 / $373.26 / $435.39
| Professional | | $315.64 | $373.26 | $435.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.78 / $289.64 / $368.63
| Professional | | $221.78 | $289.64 | $368.63 |
- 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
- $268.58 / $329.14 / $422.30
| Professional | | $268.58 | $329.14 | $422.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.27 / $1,958.52 / $5,287.00
| Professional | | $233.27 | $1,958.52 | $5,287.00 |