- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.94 / $2,168.94 / $2,168.94
| Professional | | $2,168.94 | $2,168.94 | $2,168.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,845.63 / $7,845.63 / $7,845.63
| Facility | | $7,845.63 | $7,845.63 | $7,845.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $10,863.63
| Professional | | $4,072.36 | $4,072.36 | $10,863.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,876.03 / $10,341.39 / $10,341.39
| Professional | | $9,876.03 | $10,341.39 | $10,341.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,925.62 / $9,876.03 / $13,826.44
| Professional | | $5,925.62 | $9,876.03 | $13,826.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,437.47 / $7,845.63 / $10,863.63
| Professional | | $4,437.47 | $7,845.63 | $10,863.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,319.13 / $6,170.18 / $9,400.16
| Professional | | $4,319.13 | $6,170.18 | $9,400.16 |