- 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
- $3,969.17 / $4,487.38 / $5,612.90
| Professional | | $3,969.17 | $4,487.38 | $5,612.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,642.39 / $5,617.93 / $11,634.73
| Professional | | $4,642.39 | $5,617.93 | $11,634.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,009.87 / $6,752.26 / $7,765.10
| Professional | | $6,009.87 | $6,752.26 | $7,765.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,764.00 / $5,393.21 / $6,292.08
| Professional | | $4,764.00 | $5,393.21 | $6,292.08 |
- 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
- $4,463.49 / $5,703.34 / $7,728.40
| Professional | | $4,463.49 | $5,703.34 | $7,728.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $4,410.39 / $7,024.08
| Professional | | $29.27 | $4,410.39 | $7,024.08 |