- 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
- $710.89 / $710.89 / $710.89
| Professional | | $710.89 | $710.89 | $710.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.21 / $710.89 / $853.07
| Professional | | $614.21 | $710.89 | $853.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.39 / $794.30 / $4,116.00
| Professional | | $688.39 | $794.30 | $4,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.93 / $625.58 / $710.89
| Professional | | $493.93 | $625.58 | $710.89 |
- 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
- $508.10 / $682.40 / $900.98
| Professional | | $508.10 | $682.40 | $900.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.99 / $3,098.10 / $8,000.00
| Professional | | $515.99 | $3,098.10 | $8,000.00 |