- 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
- $472.71 / $472.71 / $472.71
| Professional | | $472.71 | $472.71 | $472.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.71 / $583.71 / $595.42
| Professional | | $583.71 | $583.71 | $595.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.77 / $691.40 / $854.75
| Professional | | $631.77 | $691.40 | $854.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.66 / $560.36 / $653.76
| Professional | | $513.66 | $560.36 | $653.76 |
- 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
- $476.31 / $583.71 / $756.50
| Professional | | $476.31 | $583.71 | $756.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.79 / $3,900.00 / $8,000.00
| Professional | | $616.79 | $3,900.00 | $8,000.00 |