- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.03 / $308.81 / $583.39
| Professional | | $251.03 | $308.81 | $583.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.68 / $450.11 / $540.14
| Professional | | $364.68 | $450.11 | $540.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.77 / $515.44 / $2,077.00
| Professional | | $458.77 | $515.44 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.85 / $415.74 / $468.12
| Professional | | $365.85 | $415.74 | $468.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.50 / $450.11 / $538.67
| Professional | | $330.50 | $450.11 | $538.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.01 / $386.64 / $472.10
| Professional | | $59.01 | $386.64 | $472.10 |