- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,735.50 / $3,735.50 / $3,735.50
| Professional | | $3,735.50 | $3,735.50 | $3,735.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,379.24 / $8,379.24 / $8,379.24
| Facility | | $8,379.24 | $8,379.24 | $8,379.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $11,602.50
| Professional | | $6,652.12 | $6,652.12 | $11,602.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,547.73 / $11,044.74 / $11,044.74
| Professional | | $10,547.73 | $11,044.74 | $11,044.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,383.41 / $10,547.73 / $14,766.82
| Professional | | $7,383.41 | $10,547.73 | $14,766.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,041.76 / $8,379.24 / $11,602.50
| Professional | | $7,041.76 | $8,379.24 | $11,602.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,496.59 / $8,787.78 / $10,039.49
| Professional | | $8,496.59 | $8,787.78 | $10,039.49 |