- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.80 / $2,245.80 / $2,245.80
| Professional | | $2,245.80 | $2,245.80 | $2,245.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,072.53 / $10,072.53 / $10,072.53
| Facility | | $10,072.53 | $10,072.53 | $10,072.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $13,947.18
| Professional | | $4,728.96 | $4,728.96 | $13,947.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,679.25 / $13,276.70 / $13,276.70
| Professional | | $12,679.25 | $13,276.70 | $13,276.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,607.55 / $12,679.25 / $17,750.95
| Professional | | $7,607.55 | $12,679.25 | $17,750.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,665.53 / $10,072.53 / $13,947.18
| Professional | | $4,665.53 | $10,072.53 | $13,947.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,545.05 / $10,213.60 / $12,068.30
| Professional | | $5,545.05 | $10,213.60 | $12,068.30 |