- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.85 / $2,961.85 / $2,961.85
| Professional | | $2,961.85 | $2,961.85 | $2,961.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,114.58 / $7,114.58 / $7,114.58
| Facility | | $7,114.58 | $7,114.58 | $7,114.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,300.68 / $6,300.68 / $9,851.34
| Professional | | $6,300.68 | $6,300.68 | $9,851.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,955.76 / $9,377.76 / $9,377.76
| Professional | | $8,955.76 | $9,377.76 | $9,377.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,373.46 / $8,955.76 / $12,538.06
| Professional | | $5,373.46 | $8,955.76 | $12,538.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,153.10 / $7,114.58 / $9,851.34
| Professional | | $6,153.10 | $7,114.58 | $9,851.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,916.68 / $7,214.21 / $8,524.23
| Professional | | $3,916.68 | $7,214.21 | $8,524.23 |