- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,208.40 / $7,208.40 / $7,208.40
| Facility | | $7,208.40 | $7,208.40 | $7,208.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.57 / $4,933.43 / $8,412.65
| Professional | | $783.57 | $4,933.43 | $8,412.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,279.40 / $10,763.77 / $13,373.85
| Professional | | $10,279.40 | $10,763.77 | $13,373.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,304.95 / $8,304.95 / $8,304.95
| Professional | | $8,304.95 | $8,304.95 | $8,304.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.58 / $5,939.05 / $7,918.73
| Facility | | $740.58 | $5,939.05 | $7,918.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,650.60 / $7,208.40 / $8,281.00
| Professional | | $4,650.60 | $7,208.40 | $8,281.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,279.40 / $10,279.40 / $10,279.40
| Professional | | $10,279.40 | $10,279.40 | $10,279.40 |