- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,943.60 / $2,943.60 / $2,943.60
| Professional | | $2,943.60 | $2,943.60 | $2,943.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,687.53 / $7,687.53 / $7,687.53
| Facility | | $7,687.53 | $7,687.53 | $7,687.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $10,644.70
| Professional | | $6,541.83 | $6,541.83 | $10,644.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,677.00 / $10,132.98 / $10,132.98
| Professional | | $9,677.00 | $10,132.98 | $10,132.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,806.20 / $9,677.00 / $13,547.80
| Professional | | $5,806.20 | $9,677.00 | $13,547.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,990.47 / $7,687.53 / $10,644.70
| Professional | | $5,990.47 | $7,687.53 | $10,644.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.09 / $7,795.19 / $9,210.71
| Professional | | $4,232.09 | $7,795.19 | $9,210.71 |