- 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
- $591.17 / $591.17 / $591.17
| Professional | | $591.17 | $591.17 | $591.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.97 / $763.19 / $915.83
| Professional | | $587.97 | $763.19 | $915.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.49 / $888.14 / $5,851.00
| Professional | | $790.49 | $888.14 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.61 / $732.66 / $854.77
| Professional | | $671.61 | $732.66 | $854.77 |
- 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
- $592.85 / $763.19 / $950.85
| Professional | | $592.85 | $763.19 | $950.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.62 / $3,191.04 / $8,000.00
| Professional | | $694.62 | $3,191.04 | $8,000.00 |