- 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
- $595.35 / $914.54 / $3,258.00
| Professional | | $595.35 | $914.54 | $3,258.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.08 / $722.39 / $866.87
| Professional | | $558.08 | $722.39 | $866.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.95 / $950.45 / $5,851.00
| Professional | | $845.95 | $950.45 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.70 / $693.49 / $809.07
| Professional | | $635.70 | $693.49 | $809.07 |
- 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
- $589.47 / $722.39 / $909.00
| Professional | | $589.47 | $722.39 | $909.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.84 / $3,900.00 / $8,000.00
| Professional | | $690.84 | $3,900.00 | $8,000.00 |