- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,370.32 / $6,606.93
| Facility | | $4,466.84 | $5,370.32 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,786.30 / $6,918.31
| Professional | | $3,019.95 | $4,786.30 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $6,606.93
| Professional | | $2,951.21 | $3,090.30 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,128.31 / $8,709.64
| Professional | | $6,918.31 | $8,128.31 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,456.54 / $8,128.31
| Professional | | $5,888.44 | $6,456.54 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,495.41 / $8,317.64
| Professional | | $2,754.23 | $5,495.41 | $8,317.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,943.28 / $8,317.64
| Professional | | $4,677.35 | $7,943.28 | $8,317.64 |