- 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
- $4,073.66 / $4,073.66 / $4,657.50
| Professional | | $4,073.66 | $4,073.66 | $4,657.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,665.54 / $5,423.89 / $5,516.34
| Professional | | $4,665.54 | $5,423.89 | $5,516.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,798.73 / $6,515.04 / $7,687.75
| Professional | | $5,798.73 | $6,515.04 | $7,687.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,773.02 / $5,206.93 / $6,074.75
| Professional | | $4,773.02 | $5,206.93 | $6,074.75 |
- 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
- $4,425.89 / $5,423.89 / $7,216.32
| Professional | | $4,425.89 | $5,423.89 | $7,216.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,962.63 / $5,920.64
| Professional | | $29.27 | $3,962.63 | $5,920.64 |