- 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
- $237.90 / $289.75 / $1,297.00
| Professional | | $237.90 | $289.75 | $1,297.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.63 / $312.62 / $386.15
| Professional | | $261.63 | $312.62 | $386.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.55 / $441.85 / $3,935.00
| Professional | | $74.55 | $441.85 | $3,935.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.80 / $361.20 / $432.49
| Professional | | $283.80 | $361.20 | $432.49 |
- 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
- $315.10 / $386.15 / $468.08
| Professional | | $315.10 | $386.15 | $468.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.70 / $1,981.00 / $5,304.00
| Professional | | $287.70 | $1,981.00 | $5,304.00 |