- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.87 / $2,245.87 / $2,245.87
| Professional | | $2,245.87 | $2,245.87 | $2,245.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,070.95 / $10,070.95 / $10,070.95
| Facility | | $10,070.95 | $10,070.95 | $10,070.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $13,944.95
| Professional | | $3,790.37 | $3,790.37 | $13,944.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,677.23 / $13,274.58 / $13,274.58
| Professional | | $12,677.23 | $13,274.58 | $13,274.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,606.34 / $12,677.23 / $17,748.12
| Professional | | $7,606.34 | $12,677.23 | $17,748.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,977.55 / $10,070.95 / $13,944.95
| Professional | | $3,977.55 | $10,070.95 | $13,944.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,211.99 / $10,561.97 / $12,066.38
| Professional | | $10,211.99 | $10,561.97 | $12,066.38 |