- 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
- $3,928.80 / $4,274.46 / $5,436.92
| Professional | | $3,928.80 | $4,274.46 | $5,436.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,387.95 / $5,104.33 / $10,901.55
| Professional | | $3,387.95 | $5,104.33 | $10,901.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,702.57 / $6,407.00 / $7,368.05
| Professional | | $5,702.57 | $6,407.00 | $7,368.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,328.47 / $4,900.14 / $5,716.84
| Professional | | $4,328.47 | $4,900.14 | $5,716.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,165.13 / $5,104.33 / $7,181.36
| Professional | | $4,165.13 | $5,104.33 | $7,181.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,676.65 / $5,713.19
| Professional | | $29.27 | $3,676.65 | $5,713.19 |