- 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
- $181.47 / $348.38 / $449.28
| Professional | | $181.47 | $348.38 | $449.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.98 / $489.02 / $522.03
| Professional | | $229.98 | $489.02 | $522.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.95 / $617.17 / $709.76
| Professional | | $536.95 | $617.17 | $709.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.29 / $431.31 / $584.66
| Professional | | $316.29 | $431.31 | $584.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.00 / $1,106.00 / $1,106.00
| Facility | | $1,106.00 | $1,106.00 | $1,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.25 / $522.03 / $625.20
| Professional | | $460.25 | $522.03 | $625.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.66 / $380.67 / $3,831.00
| Professional | | $68.66 | $380.67 | $3,831.00 |