- 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
- $601.64 / $675.84 / $1,055.05
| Professional | | $601.64 | $675.84 | $1,055.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.08 / $823.01 / $987.62
| Professional | | $711.08 | $823.01 | $987.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.62 / $959.07 / $7,637.00
| Professional | | $853.62 | $959.07 | $7,637.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.25 / $790.09 / $921.77
| Professional | | $724.25 | $790.09 | $921.77 |
- 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
- $604.00 / $796.40 / $1,048.41
| Professional | | $604.00 | $796.40 | $1,048.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.36 / $3,900.00 / $8,000.00
| Professional | | $782.36 | $3,900.00 | $8,000.00 |