- 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
- $3,212.67 / $3,487.61 / $4,404.51
| Professional | | $3,212.67 | $3,487.61 | $4,404.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,176.29 / $4,173.05 / $8,882.85
| Professional | | $3,176.29 | $4,173.05 | $8,882.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,680.22 / $5,258.38 / $6,047.14
| Professional | | $4,680.22 | $5,258.38 | $6,047.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,538.75 / $4,006.13 / $4,673.82
| Professional | | $3,538.75 | $4,006.13 | $4,673.82 |
- 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
- $3,405.21 / $4,173.05 / $7,517.23
| Professional | | $3,405.21 | $4,173.05 | $7,517.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,144.51 / $4,629.70
| Professional | | $29.27 | $3,144.51 | $4,629.70 |