- 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
- $622.59 / $799.98 / $2,587.00
| Professional | | $622.59 | $799.98 | $2,587.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.32 / $802.68 / $963.21
| Professional | | $618.32 | $802.68 | $963.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.56 / $910.05 / $1,074.42
| Professional | | $831.56 | $910.05 | $1,074.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.35 / $770.57 / $899.00
| Professional | | $706.35 | $770.57 | $899.00 |
- 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
- $629.41 / $802.68 / $1,007.33
| Professional | | $629.41 | $802.68 | $1,007.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.14 / $3,900.00 / $8,000.00
| Professional | | $762.14 | $3,900.00 | $8,000.00 |