- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,398.34 / $3,398.34 / $3,398.34
| Professional | | $3,398.34 | $3,398.34 | $3,398.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,762.04 / $8,762.04 / $8,762.04
| Facility | | $8,762.04 | $8,762.04 | $8,762.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,261.93 / $12,132.56 / $12,132.56
| Professional | | $7,261.93 | $12,132.56 | $12,132.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,029.60 / $11,549.31 / $11,549.31
| Professional | | $11,029.60 | $11,549.31 | $11,549.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,617.76 / $11,029.60 / $15,441.44
| Professional | | $6,617.76 | $11,029.60 | $15,441.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,059.89 / $8,762.04 / $12,132.56
| Professional | | $7,059.89 | $8,762.04 | $12,132.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,823.63 / $8,884.76 / $10,498.14
| Professional | | $4,823.63 | $8,884.76 | $10,498.14 |