- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $2,747.00 / $5,484.00
| Facility | | $1,924.00 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.01 / $1,063.01 / $1,063.01
| Professional | | $1,063.01 | $1,063.01 | $1,063.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.05 / $1,224.72 / $1,257.95
| Professional | | $891.05 | $1,224.72 | $1,257.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.05 / $1,722.92 / $1,868.87
| Professional | | $891.05 | $1,722.92 | $1,868.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $63.75 / $96.00
| Professional | | $12.00 | $63.75 | $96.00 |