- 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
- $604.37 / $604.37 / $607.79
| Professional | | $604.37 | $604.37 | $607.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.72 / $767.31 / $767.31
| Professional | | $590.72 | $767.31 | $767.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.97 / $921.26 / $1,087.08
| Professional | | $819.97 | $921.26 | $1,087.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.24 / $736.62 / $859.39
| Professional | | $675.24 | $736.62 | $859.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,155.00 / $2,155.00
| Facility | | $2,155.00 | $2,155.00 | $2,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.13 / $767.31 / $982.50
| Professional | | $626.13 | $767.31 | $982.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $560.34 / $970.82
| Professional | | $29.27 | $560.34 | $970.82 |