- 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
- $632.65 / $632.65 / $745.06
| Professional | | $632.65 | $632.65 | $745.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.46 / $858.41 / $1,030.09
| Professional | | $700.46 | $858.41 | $1,030.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.92 / $1,021.08 / $1,256.26
| Professional | | $867.92 | $1,021.08 | $1,256.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.16 / $755.40 / $863.42
| Professional | | $633.16 | $755.40 | $863.42 |
- 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
- $686.51 / $858.41 / $1,128.42
| Professional | | $686.51 | $858.41 | $1,128.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.58 / $3,098.10 / $8,000.00
| Professional | | $654.58 | $3,098.10 | $8,000.00 |