- 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
- $720.27 / $745.38 / $745.38
| Professional | | $720.27 | $745.38 | $745.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.28 / $871.93 / $871.93
| Professional | | $692.28 | $871.93 | $871.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.05 / $1,115.72 / $1,316.55
| Professional | | $993.05 | $1,115.72 | $1,316.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.29 / $837.05 / $976.56
| Professional | | $767.29 | $837.05 | $976.56 |
- 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
- $711.49 / $873.06 / $1,173.48
| Professional | | $711.49 | $873.06 | $1,173.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $800.52 / $1,192.16
| Professional | | $29.27 | $800.52 | $1,192.16 |