- 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
- $3,042.03 / $3,042.03 / $3,042.03
| Professional | | $3,042.03 | $3,042.03 | $3,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,118.37 / $4,004.34 / $4,805.21
| Professional | | $3,118.37 | $4,004.34 | $4,805.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,565.72 / $5,129.74 / $5,899.20
| Professional | | $4,565.72 | $5,129.74 | $5,899.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,523.82 / $3,844.16 / $4,484.85
| Professional | | $3,523.82 | $3,844.16 | $4,484.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,340.00 / $3,340.00 / $3,340.00
| Facility | | $3,340.00 | $3,340.00 | $3,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,267.54 / $4,004.34 / $5,203.77
| Professional | | $3,267.54 | $4,004.34 | $5,203.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,309.28 / $4,355.10
| Professional | | $29.27 | $3,309.28 | $4,355.10 |