- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,478.30 / $6,478.30 / $6,478.30
| Professional | | $6,478.30 | $6,478.30 | $6,478.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,581.25 / $13,581.25 / $13,581.25
| Facility | | $13,581.25 | $13,581.25 | $13,581.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,812.54 / $9,812.54 / $18,805.58
| Professional | | $9,812.54 | $9,812.54 | $18,805.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,034.65 / $4,034.65 / $4,034.65
| Professional | | $4,034.65 | $4,034.65 | $4,034.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,967.19 / $17,095.98 / $23,934.37
| Professional | | $11,967.19 | $17,095.98 | $23,934.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,537.40 / $15,984.74 / $18,805.58
| Professional | | $11,537.40 | $15,984.74 | $18,805.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,771.46 / $14,243.42 / $16,272.21
| Professional | | $13,771.46 | $14,243.42 | $16,272.21 |