- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,287.00 / $6,287.00 / $6,287.00
| Facility | | $6,287.00 | $6,287.00 | $6,287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.82 / $3,808.72 / $31,896.49
| Professional | | $3,660.82 | $3,808.72 | $31,896.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,287.01 / $6,287.01 / $6,287.01
| Facility | | $6,287.01 | $6,287.01 | $6,287.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $3,660.83 / $3,660.83
| Professional | | $3,660.83 | $3,660.83 | $3,660.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,758.33 / $3,758.33 / $3,758.33
| Professional | | $3,758.33 | $3,758.33 | $3,758.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,026.92 / $4,393.00 / $5,125.17
| Professional | | $4,026.92 | $4,393.00 | $5,125.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.83 / $4,260.06 / $5,491.25
| Professional | | $3,660.83 | $4,260.06 | $5,491.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,472.58 / $3,482.15 / $4,295.56
| Professional | | $2,472.58 | $3,482.15 | $4,295.56 |