- 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
- $762.20 / $762.20 / $1,189.33
| Professional | | $762.20 | $762.20 | $1,189.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.49 / $939.83 / $1,127.79
| Professional | | $729.49 | $939.83 | $1,127.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.44 / $1,103.80 / $3,857.00
| Professional | | $982.44 | $1,103.80 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.05 / $902.23 / $1,052.59
| Professional | | $827.05 | $902.23 | $1,052.59 |
- 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
- $752.78 / $939.83 / $1,202.88
| Professional | | $752.78 | $939.83 | $1,202.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.42 / $5,316.74 / $11,157.30
| Professional | | $900.42 | $5,316.74 | $11,157.30 |