- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,123.30 / $18,123.30 / $18,123.30
| Facility | | $18,123.30 | $18,123.30 | $18,123.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.51 / $6,893.03 / $9,693.00
| Professional | | $2,179.51 | $6,893.03 | $9,693.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,821.49 / $2,821.49 / $2,821.49
| Professional | | $2,821.49 | $2,821.49 | $2,821.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,705.43 / $5,585.67 / $6,178.84
| Professional | | $4,705.43 | $5,585.67 | $6,178.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,233.25 / $3,766.90 / $4,394.71
| Professional | | $3,233.25 | $3,766.90 | $4,394.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.64 / $4,542.97 / $5,064.60
| Professional | | $2,171.64 | $4,542.97 | $5,064.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.35 / $3,130.86 / $3,683.36
| Professional | | $2,578.35 | $3,130.86 | $3,683.36 |