- 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
- $666.30 / $718.56 / $906.01
| Professional | | $666.30 | $718.56 | $906.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.99 / $935.84 / $1,898.97
| Professional | | $732.99 | $935.84 | $1,898.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.04 / $1,121.32 / $1,289.52
| Professional | | $998.04 | $1,121.32 | $1,289.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.59 / $898.40 / $1,048.14
| Professional | | $793.59 | $898.40 | $1,048.14 |
- 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
- $707.25 / $935.84 / $1,285.19
| Professional | | $707.25 | $935.84 | $1,285.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $728.57 / $1,161.14
| Professional | | $29.27 | $728.57 | $1,161.14 |