- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.58 / $1,960.58 / $1,960.58
| Professional | | $1,960.58 | $1,960.58 | $1,960.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,719.82 / $8,719.82 / $8,719.82
| Facility | | $8,719.82 | $8,719.82 | $8,719.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,578.08 / $12,074.07 / $12,074.07
| Professional | | $3,578.08 | $12,074.07 | $12,074.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,976.43 / $11,493.64 / $11,493.64
| Professional | | $10,976.43 | $11,493.64 | $11,493.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,585.86 / $10,976.43 / $15,367.00
| Professional | | $6,585.86 | $10,976.43 | $15,367.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,689.51 / $7,649.53 / $12,074.07
| Professional | | $3,689.51 | $7,649.53 | $12,074.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,800.38 / $6,857.68 / $10,447.53
| Professional | | $4,800.38 | $6,857.68 | $10,447.53 |