- 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
- $566.35 / $566.35 / $566.35
| Professional | | $566.35 | $566.35 | $566.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.41 / $743.25 / $891.90
| Professional | | $573.41 | $743.25 | $891.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.19 / $843.98 / $996.42
| Professional | | $771.19 | $843.98 | $996.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.05 / $713.52 / $832.44
| Professional | | $654.05 | $713.52 | $832.44 |
- 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
- $579.49 / $743.25 / $928.73
| Professional | | $579.49 | $743.25 | $928.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.17 / $3,191.04 / $8,000.00
| Professional | | $672.17 | $3,191.04 | $8,000.00 |