- 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
- $497.26 / $582.71 / $582.71
| Professional | | $497.26 | $582.71 | $582.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.16 / $875.30 / $875.30
| Professional | | $635.16 | $875.30 | $875.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.13 / $1,121.71 / $5,879.00
| Professional | | $957.13 | $1,121.71 | $5,879.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.26 / $840.29 / $980.34
| Professional | | $770.26 | $840.29 | $980.34 |
- 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
- $714.24 / $875.30 / $1,061.19
| Professional | | $714.24 | $875.30 | $1,061.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.91 / $5,316.74 / $11,157.30
| Professional | | $781.91 | $5,316.74 | $11,157.30 |