- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,924.00 / $2,747.00 / $5,484.00
| Facility | | $1,924.00 | $2,747.00 | $5,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.21 / $2,784.21 / $2,784.21
| Professional | | $2,784.21 | $2,784.21 | $2,784.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,176.62 / $4,050.29 / $4,860.35
| Professional | | $3,176.62 | $4,050.29 | $4,860.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,323.18 / $4,731.25 / $5,585.81
| Professional | | $4,323.18 | $4,731.25 | $5,585.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,564.25 / $3,888.28 / $4,536.32
| Professional | | $3,564.25 | $3,888.28 | $4,536.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,298.08 / $4,050.29 / $5,236.92
| Professional | | $3,298.08 | $4,050.29 | $5,236.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,954.30 / $4,448.83
| Professional | | $29.27 | $2,954.30 | $4,448.83 |