- 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
- $2,909.54 / $2,909.54 / $3,339.20
| Professional | | $2,909.54 | $2,909.54 | $3,339.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,320.29 / $3,916.05 / $3,916.05
| Professional | | $3,320.29 | $3,916.05 | $3,916.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,225.27 / $4,747.22 / $5,601.72
| Professional | | $4,225.27 | $4,747.22 | $5,601.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,446.12 / $3,759.41 / $4,385.97
| Professional | | $3,446.12 | $3,759.41 | $4,385.97 |
- 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
- $3,195.50 / $3,916.05 / $5,111.87
| Professional | | $3,195.50 | $3,916.05 | $5,111.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,081.48 / $4,348.08
| Professional | | $29.27 | $3,081.48 | $4,348.08 |