- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.69 / $2,913.46 / $3,739.20
| Facility | | $2,570.69 | $2,913.46 | $3,739.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.58 / $320.58 / $320.58
| Professional | | $320.58 | $320.58 | $320.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.20 / $3,739.20 / $3,739.20
| Professional | | $3,739.20 | $3,739.20 | $3,739.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,917.59 / $4,697.41 / $5,196.25
| Professional | | $3,917.59 | $4,697.41 | $5,196.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,427.60 / $3,739.20 / $4,362.39
| Professional | | $3,427.60 | $3,739.20 | $4,362.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,125.73 / $3,739.20 / $4,674.00
| Professional | | $3,125.73 | $3,739.20 | $4,674.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,648.60 / $4,580.52 / $7,011.00
| Professional | | $2,648.60 | $4,580.52 | $7,011.00 |