- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.55 / $2,747.00 / $5,484.00
| Facility | | $1,635.55 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.65 / $524.89 / $634.17
| Professional | | $418.65 | $524.89 | $634.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.36 / $815.56 / $974.54
| Professional | | $665.36 | $815.56 | $974.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.50 / $1,109.09 / $1,393.73
| Professional | | $981.50 | $1,109.09 | $1,393.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.98 / $878.15 / $1,091.48
| Professional | | $689.98 | $878.15 | $1,091.48 |
- 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
- $795.22 / $974.54 / $1,243.33
| Professional | | $795.22 | $974.54 | $1,243.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.45 / $3,191.04 / $8,000.00
| Professional | | $729.45 | $3,191.04 | $8,000.00 |