- 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
- $433.36 / $433.36 / $573.54
| Professional | | $433.36 | $433.36 | $573.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.90 / $665.94 / $799.13
| Professional | | $515.90 | $665.94 | $799.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.51 / $681.72 / $822.31
| Professional | | $576.51 | $681.72 | $822.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.60 / $564.72 / $665.94
| Professional | | $408.60 | $564.72 | $665.94 |
- 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
- $535.72 / $665.94 / $869.84
| Professional | | $535.72 | $665.94 | $869.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.65 / $3,098.10 / $8,000.00
| Professional | | $477.65 | $3,098.10 | $8,000.00 |