- 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
- $199.06 / $546.10 / $3,179.76
| Professional | | $199.06 | $546.10 | $3,179.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.95 / $430.95 / $659.39
| Professional | | $430.95 | $430.95 | $659.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.62 / $781.96 / $8,902.00
| Professional | | $679.62 | $781.96 | $8,902.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.24 / $413.71 / $482.66
| Professional | | $379.24 | $413.71 | $482.66 |
- 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
- $351.66 / $442.52 / $571.58
| Professional | | $351.66 | $442.52 | $571.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.93 / $2,582.96 / $6,124.00
| Professional | | $483.93 | $2,582.96 | $6,124.00 |