- 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
- $549.09 / $650.79 / $650.79
| Professional | | $549.09 | $650.79 | $650.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.99 / $889.13 / $889.13
| Professional | | $721.99 | $889.13 | $889.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.41 / $1,046.69 / $1,267.98
| Professional | | $956.41 | $1,046.69 | $1,267.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.43 / $853.56 / $995.82
| Professional | | $782.43 | $853.56 | $995.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.03 / $920.67 / $1,146.34
| Professional | | $842.03 | $920.67 | $1,146.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $854.92 / $1,015.96
| Professional | | $29.27 | $854.92 | $1,015.96 |