- 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
- $340.39 / $340.39 / $372.90
| Professional | | $340.39 | $340.39 | $372.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.52 / $446.79 / $446.79
| Professional | | $358.52 | $446.79 | $446.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.35 / $584.63 / $689.86
| Professional | | $520.35 | $584.63 | $689.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.17 / $428.92 / $500.40
| Professional | | $393.17 | $428.92 | $500.40 |
- 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
- $364.58 / $446.79 / $569.21
| Professional | | $364.58 | $446.79 | $569.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.99 / $441.68 / $495.92
| Professional | | $61.99 | $441.68 | $495.92 |