- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,417.20 / $11,417.20 / $11,417.20
| Facility | | $11,417.20 | $11,417.20 | $11,417.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,417.19 / $11,417.19 / $11,417.19
| Facility | | $11,417.19 | $11,417.19 | $11,417.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $6,408.38
| Professional | | $6,408.38 | $6,408.38 | $6,408.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,882.79 / $8,882.79 / $8,882.79
| Professional | | $8,882.79 | $8,882.79 | $8,882.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,049.21 / $7,690.05 / $8,971.73
| Professional | | $7,049.21 | $7,690.05 | $8,971.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $7,300.92 / $9,612.57
| Professional | | $6,408.38 | $7,300.92 | $9,612.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.62 / $6,460.03 / $7,364.08
| Professional | | $228.62 | $6,460.03 | $7,364.08 |