- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,415.20 / $7,270.56 / $9,331.20
| Facility | | $6,415.20 | $7,270.56 | $9,331.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $2,480.40
| Professional | | $2,480.40 | $2,480.40 | $2,480.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,331.20 / $9,331.20 / $9,331.20
| Professional | | $9,331.20 | $9,331.20 | $9,331.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,328.17 / $8,786.87 / $9,720.00
| Professional | | $7,328.17 | $8,786.87 | $9,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,553.60 / $9,331.20 / $10,886.40
| Professional | | $8,553.60 | $9,331.20 | $10,886.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,776.00 / $9,331.20 / $11,664.00
| Professional | | $7,776.00 | $9,331.20 | $11,664.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,609.60 / $10,497.60 / $17,496.00
| Professional | | $6,609.60 | $10,497.60 | $17,496.00 |