- 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
- $491.63 / $548.12 / $810.21
| Professional | | $491.63 | $548.12 | $810.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.00 / $979.55 / $6,008.36
| Professional | | $539.00 | $979.55 | $6,008.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.38 / $777.04 / $906.54
| Professional | | $686.38 | $777.04 | $906.54 |
- 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
- $546.90 / $832.66 / $1,438.98
| Professional | | $546.90 | $832.66 | $1,438.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.25 / $516.66 / $778.04
| Professional | | $97.25 | $516.66 | $778.04 |