- 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
- $3,371.83 / $3,615.72 / $4,367.89
| Professional | | $3,371.83 | $3,615.72 | $4,367.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,706.65 / $4,626.16 / $9,184.94
| Professional | | $3,706.65 | $4,626.16 | $9,184.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,569.42 / $5,987.13 / $6,269.24
| Professional | | $5,569.42 | $5,987.13 | $6,269.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,713.54 / $4,204.01 / $4,904.68
| Professional | | $3,713.54 | $4,204.01 | $4,904.68 |
- 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
- $3,573.41 / $4,557.45 / $6,539.86
| Professional | | $3,573.41 | $4,557.45 | $6,539.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.03 / $4,332.18 / $4,864.22
| Professional | | $608.03 | $4,332.18 | $4,864.22 |