- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,195.23 / $3,621.26 / $4,647.60
| Facility | | $3,195.23 | $3,621.26 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,873.00 / $3,873.00 / $3,873.00
| Professional | | $3,873.00 | $3,873.00 | $3,873.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,647.60 / $4,647.60 / $4,647.60
| Professional | | $4,647.60 | $4,647.60 | $4,647.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,256.00 / $4,456.54 / $5,320.00
| Professional | | $4,256.00 | $4,456.54 | $5,320.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,260.30 / $4,647.60 / $5,422.20
| Professional | | $4,260.30 | $4,647.60 | $5,422.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,620.55 / $4,647.60 / $5,809.50
| Professional | | $3,620.55 | $4,647.60 | $5,809.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,292.05 / $5,693.31 / $8,714.25
| Professional | | $3,292.05 | $5,693.31 | $8,714.25 |