- 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
- $2,638.16 / $3,112.93 / $3,112.93
| Professional | | $2,638.16 | $3,112.93 | $3,112.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.58 / $4,088.65 / $4,297.80
| Professional | | $3,500.58 | $4,088.65 | $4,297.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,604.50 / $5,039.12 / $6,104.48
| Professional | | $4,604.50 | $5,039.12 | $6,104.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,598.01 / $3,925.10 / $4,579.29
| Professional | | $3,598.01 | $3,925.10 | $4,579.29 |
- 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
- $3,336.34 / $4,088.65 / $5,458.56
| Professional | | $3,336.34 | $4,088.65 | $5,458.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,022.28 / $4,515.64
| Professional | | $29.27 | $3,022.28 | $4,515.64 |