- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.00 / $2,747.00 / $6,084.00
| Facility | | $2,528.00 | $2,747.00 | $6,084.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.73 / $767.48 / $9,952.16
| Professional | | $488.73 | $767.48 | $9,952.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,028.73 / $7,388.15 / $8,865.78
| Professional | | $6,028.73 | $7,388.15 | $8,865.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.20 / $980.59 / $9,834.43
| Professional | | $793.20 | $980.59 | $9,834.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.54 / $6,265.15 / $7,388.15
| Professional | | $544.54 | $6,265.15 | $7,388.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,028.00 / $3,028.00 / $3,028.00
| Facility | | $3,028.00 | $3,028.00 | $3,028.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,028.73 / $7,388.15 / $11,609.34
| Professional | | $6,028.73 | $7,388.15 | $11,609.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.83 / $9,814.00 / $12,881.00
| Professional | | $602.83 | $9,814.00 | $12,881.00 |