- 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
- $4,465.27 / $4,778.43 / $5,833.91
| Professional | | $4,465.27 | $4,778.43 | $5,833.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,277.75 / $5,700.79 / $12,191.54
| Professional | | $3,277.75 | $5,700.79 | $12,191.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,341.44 / $7,124.80 / $8,193.52
| Professional | | $6,341.44 | $7,124.80 | $8,193.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,834.27 / $5,472.76 / $6,384.88
| Professional | | $4,834.27 | $5,472.76 | $6,384.88 |
- 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
- $4,651.84 / $6,036.30 / $8,635.79
| Professional | | $4,651.84 | $6,036.30 | $8,635.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $4,239.26 / $6,383.82
| Professional | | $29.27 | $4,239.26 | $6,383.82 |