- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,964.00 / $9,964.00 / $9,964.00
| Facility | | $9,964.00 | $9,964.00 | $9,964.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.06 / $1,070.64 / $6,930.00
| Professional | | $1,029.06 | $1,070.64 | $6,930.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,351.58 / $1,590.10
| Professional | | $1,053.85 | $1,351.58 | $1,590.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.93 / $1,425.06 / $1,425.06
| Professional | | $1,360.93 | $1,425.06 | $1,425.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.64 / $1,413.42 / $1,648.99
| Professional | | $1,295.64 | $1,413.42 | $1,648.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.20 / $1,431.09 / $1,590.10
| Professional | | $1,033.20 | $1,431.09 | $1,590.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.59 / $1,071.59 / $1,071.59
| Professional | | $1,071.59 | $1,071.59 | $1,071.59 |