- 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
- $3,966.70 / $4,331.24 / $5,644.99
| Professional | | $3,966.70 | $4,331.24 | $5,644.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,340.43 / $5,191.29 / $11,031.03
| Professional | | $3,340.43 | $5,191.29 | $11,031.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,729.01 / $6,436.71 / $7,402.22
| Professional | | $5,729.01 | $6,436.71 | $7,402.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,402.21 / $4,983.64 / $5,814.24
| Professional | | $4,402.21 | $4,983.64 | $5,814.24 |
- 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
- $4,236.09 / $5,191.29 / $7,283.53
| Professional | | $4,236.09 | $5,191.29 | $7,283.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,849.13 / $5,751.06
| Professional | | $29.27 | $3,849.13 | $5,751.06 |