- 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
- $3,399.49 / $3,636.64 / $4,563.87
| Professional | | $3,399.49 | $3,636.64 | $4,563.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,824.31 / $4,411.95 / $9,313.09
| Professional | | $2,824.31 | $4,411.95 | $9,313.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,915.89 / $5,523.15 / $6,351.62
| Professional | | $4,915.89 | $5,523.15 | $6,351.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,741.33 / $4,235.47 / $4,941.38
| Professional | | $3,741.33 | $4,235.47 | $4,941.38 |
- 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
- $3,590.41 / $4,587.74 / $6,611.90
| Professional | | $3,590.41 | $4,587.74 | $6,611.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,196.79 / $4,876.47
| Professional | | $29.27 | $3,196.79 | $4,876.47 |