- 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
- $393.81 / $627.71 / $1,099.46
| Professional | | $393.81 | $627.71 | $1,099.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.93 / $842.51 / $1,011.02
| Professional | | $727.93 | $842.51 | $1,011.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.80 / $833.70 / $5,851.00
| Professional | | $723.80 | $833.70 | $5,851.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.51 / $701.61 / $842.51
| Professional | | $514.51 | $701.61 | $842.51 |
- 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
- $600.11 / $758.26 / $845.97
| Professional | | $600.11 | $758.26 | $845.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.53 / $3,098.10 / $8,000.00
| Professional | | $554.53 | $3,098.10 | $8,000.00 |