- 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
- $3,047.85 / $3,190.90 / $4,258.39
| Professional | | $3,047.85 | $3,190.90 | $4,258.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,227.70 / $14,093.88 / $16,886.06
| Professional | | $4,227.70 | $14,093.88 | $16,886.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,582.63 / $5,148.72 / $5,921.03
| Professional | | $4,582.63 | $5,148.72 | $5,921.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,635.24 / $4,115.35 / $4,801.26
| Professional | | $3,635.24 | $4,115.35 | $4,801.26 |
- 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
- $3,394.14 / $4,286.84 / $5,878.55
| Professional | | $3,394.14 | $4,286.84 | $5,878.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,308.90 / $5,265.95
| Professional | | $29.27 | $3,308.90 | $5,265.95 |