- 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
- $3,885.70 / $4,280.27 / $6,081.96
| Professional | | $3,885.70 | $4,280.27 | $6,081.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,570.56 / $5,010.60 / $10,638.98
| Professional | | $3,570.56 | $5,010.60 | $10,638.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,707.43 / $6,412.46 / $7,374.33
| Professional | | $5,707.43 | $6,412.46 | $7,374.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,248.99 / $4,810.18 / $5,611.87
| Professional | | $4,248.99 | $4,810.18 | $5,611.87 |
- 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
- $4,088.65 / $5,248.89 / $7,028.13
| Professional | | $4,088.65 | $5,248.89 | $7,028.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,713.95 / $5,592.77
| Professional | | $29.27 | $3,713.95 | $5,592.77 |