- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,583.13 / $3,107.00 / $8,431.00
| Facility | | $2,583.13 | $3,107.00 | $8,431.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.94 / $666.50 / $690.97
| Professional | | $575.94 | $666.50 | $690.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.63 / $829.20 / $995.04
| Professional | | $676.63 | $829.20 | $995.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.13 / $1,013.06 / $1,275.19
| Professional | | $881.13 | $1,013.06 | $1,275.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.19 / $729.70 / $829.20
| Professional | | $604.19 | $729.70 | $829.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.00 / $1,981.00 / $1,981.00
| Facility | | $1,981.00 | $1,981.00 | $1,981.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.63 / $829.20 / $1,128.24
| Professional | | $676.63 | $829.20 | $1,128.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.26 / $4,682.00 / $11,157.30
| Professional | | $600.26 | $4,682.00 | $11,157.30 |