- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,171.20 / $4,171.20 / $4,171.20
| Professional | | $4,171.20 | $4,171.20 | $4,171.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,752.35 / $4,814.96 / $5,777.96
| Professional | | $3,752.35 | $4,814.96 | $5,777.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,801.56 / $6,369.11 / $7,495.96
| Professional | | $5,801.56 | $6,369.11 | $7,495.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,237.17 / $4,622.35 / $5,392.76
| Professional | | $4,237.17 | $4,622.35 | $5,392.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,929.01 / $4,814.96 / $6,280.11
| Professional | | $3,929.01 | $4,814.96 | $6,280.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $4,577.97 / $5,246.49
| Professional | | $29.27 | $4,577.97 | $5,246.49 |