- 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 / $491.63 / $837.53
| Professional | | $491.63 | $491.63 | $837.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.00 / $1,104.75 / $6,910.27
| Professional | | $539.00 | $1,104.75 | $6,910.27 |
- 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
- $601.76 / $937.13 / $1,815.50
| Professional | | $601.76 | $937.13 | $1,815.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.25 / $516.66 / $778.04
| Professional | | $97.25 | $516.66 | $778.04 |