- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,332.60 / $10,332.60 / $10,332.60
| Facility | | $10,332.60 | $10,332.60 | $10,332.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,678.89 / $4,854.35 / $4,971.34
| Professional | | $4,678.89 | $4,854.35 | $4,971.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,332.58 / $10,332.58 / $10,332.58
| Facility | | $10,332.58 | $10,332.58 | $10,332.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,971.34 / $4,971.34 / $5,967.07
| Professional | | $4,971.34 | $4,971.34 | $5,967.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,837.91 / $5,837.91 / $5,837.91
| Professional | | $5,837.91 | $5,837.91 | $5,837.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $670.00
| Professional | | $5.00 | $5.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,830.47 / $4,873.85 / $7,310.79
| Professional | | $4,830.47 | $4,873.85 | $7,310.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,826.52 / $4,107.54 / $5,413.32
| Professional | | $3,826.52 | $4,107.54 | $5,413.32 |