- 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
- $3,543.72 / $4,034.29 / $5,090.43
| Professional | | $3,543.72 | $4,034.29 | $5,090.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,213.55 / $5,111.93 / $10,548.64
| Professional | | $4,213.55 | $5,111.93 | $10,548.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,472.81 / $6,148.87 / $7,071.20
| Professional | | $5,472.81 | $6,148.87 | $7,071.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,334.91 / $4,907.45 / $5,725.36
| Professional | | $4,334.91 | $4,907.45 | $5,725.36 |
- 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
- $4,064.33 / $5,111.93 / $7,021.53
| Professional | | $4,064.33 | $5,111.93 | $7,021.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $4,003.07 / $6,374.27
| Professional | | $29.27 | $4,003.07 | $6,374.27 |