- 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
- $535.26 / $651.75 / $2,820.00
| Professional | | $535.26 | $651.75 | $2,820.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.39 / $820.88 / $985.05
| Professional | | $630.39 | $820.88 | $985.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.70 / $946.80 / $5,851.00
| Professional | | $842.70 | $946.80 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.37 / $788.04 / $919.38
| Professional | | $722.37 | $788.04 | $919.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.98 / $820.88 / $1,017.06
| Professional | | $632.98 | $820.88 | $1,017.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.55 / $3,191.04 / $8,000.00
| Professional | | $746.55 | $3,191.04 | $8,000.00 |