- 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
- $553.41 / $553.41 / $706.20
| Professional | | $553.41 | $553.41 | $706.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.97 / $848.60 / $1,018.32
| Professional | | $656.97 | $848.60 | $1,018.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.13 / $910.60 / $1,051.29
| Professional | | $754.13 | $910.60 | $1,051.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.36 / $739.58 / $848.60
| Professional | | $542.36 | $739.58 | $848.60 |
- 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
- $685.68 / $848.60 / $1,106.31
| Professional | | $685.68 | $848.60 | $1,106.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.39 / $3,098.10 / $8,000.00
| Professional | | $593.39 | $3,098.10 | $8,000.00 |