- 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
- $223.00 / $273.60 / $389.83
| Professional | | $223.00 | $273.60 | $389.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.57 / $322.04 / $341.59
| Professional | | $277.57 | $322.04 | $341.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.11 / $439.42 / $518.52
| Professional | | $391.11 | $439.42 | $518.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.39 / $309.16 / $360.68
| Professional | | $283.39 | $309.16 | $360.68 |
- 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
- $262.77 / $322.04 / $431.63
| Professional | | $262.77 | $322.04 | $431.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $237.29 / $500.02
| Professional | | $29.27 | $237.29 | $500.02 |