- 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
- $3,473.92 / $3,767.85 / $4,959.67
| Professional | | $3,473.92 | $3,767.85 | $4,959.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,799.09 / $5,035.06 / $10,474.61
| Professional | | $3,799.09 | $5,035.06 | $10,474.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,421.23 / $6,090.92 / $7,004.56
| Professional | | $5,421.23 | $6,090.92 | $7,004.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,269.72 / $4,833.66 / $5,639.27
| Professional | | $4,269.72 | $4,833.66 | $5,639.27 |
- 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
- $3,899.81 / $5,122.31 / $6,935.30
| Professional | | $3,899.81 | $5,122.31 | $6,935.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,704.67 / $5,578.80
| Professional | | $29.27 | $3,704.67 | $5,578.80 |