- 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
- $3,546.60 / $3,546.60 / $4,050.59
| Professional | | $3,546.60 | $3,546.60 | $4,050.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,054.98 / $4,728.41 / $4,793.68
| Professional | | $4,054.98 | $4,728.41 | $4,793.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,049.82 / $5,673.62 / $6,694.87
| Professional | | $5,049.82 | $5,673.62 | $6,694.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,161.00 / $4,539.28 / $5,295.82
| Professional | | $4,161.00 | $4,539.28 | $5,295.82 |
- 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
- $3,858.38 / $4,728.41 / $6,178.73
| Professional | | $3,858.38 | $4,728.41 | $6,178.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,450.86 / $5,196.60
| Professional | | $29.27 | $3,450.86 | $5,196.60 |