- 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
- $597.36 / $624.90 / $624.90
| Professional | | $597.36 | $624.90 | $624.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.89 / $725.69 / $725.69
| Professional | | $573.89 | $725.69 | $725.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $832.50 / $935.34 / $1,103.70
| Professional | | $832.50 | $935.34 | $1,103.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.61 / $696.66 / $812.77
| Professional | | $638.61 | $696.66 | $812.77 |
- 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
- $592.16 / $725.69 / $930.27
| Professional | | $592.16 | $725.69 | $930.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.03 / $3,900.00 / $8,000.00
| Professional | | $693.03 | $3,900.00 | $8,000.00 |