- 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
- $836.57 / $836.57 / $2,149.54
| Professional | | $836.57 | $836.57 | $2,149.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.84 / $2,336.15 / $2,803.38
| Professional | | $1,853.84 | $2,336.15 | $2,803.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.99 / $1,434.34 / $3,245.82
| Professional | | $1,212.99 | $1,434.34 | $3,245.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.22 / $1,981.06 / $2,336.15
| Professional | | $861.22 | $1,981.06 | $2,336.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.30 / $2,295.44 / $3,385.61
| Professional | | $1,906.30 | $2,295.44 | $3,385.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.87 / $4,682.00 / $11,157.30
| Professional | | $921.87 | $4,682.00 | $11,157.30 |