- 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
- $642.20 / $642.20 / $642.20
| Professional | | $642.20 | $642.20 | $642.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.12 / $738.56 / $886.28
| Professional | | $638.12 | $738.56 | $886.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.69 / $844.53 / $1,023.08
| Professional | | $771.69 | $844.53 | $1,023.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.94 / $709.02 / $827.19
| Professional | | $649.94 | $709.02 | $827.19 |
- 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
- $527.08 / $711.53 / $921.12
| Professional | | $527.08 | $711.53 | $921.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.27 / $3,900.00 / $8,000.00
| Professional | | $707.27 | $3,900.00 | $8,000.00 |