- 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
- $2,830.56 / $2,830.56 / $3,280.57
| Professional | | $2,830.56 | $2,830.56 | $3,280.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,253.51 / $3,935.61 / $3,935.61
| Professional | | $3,253.51 | $3,935.61 | $3,935.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.87 / $4,792.83 / $5,655.54
| Professional | | $4,265.87 | $4,792.83 | $5,655.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,463.34 / $3,778.19 / $4,407.89
| Professional | | $3,463.34 | $3,778.19 | $4,407.89 |
- 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
- $3,460.72 / $3,719.90 / $5,075.10
| Professional | | $3,460.72 | $3,719.90 | $5,075.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,916.56 / $4,389.85
| Professional | | $29.27 | $2,916.56 | $4,389.85 |