- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,461.96 / $3,461.96 / $3,461.96
| Professional | | $3,461.96 | $3,461.96 | $3,461.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,239.32 / $8,239.32 / $8,239.32
| Facility | | $8,239.32 | $8,239.32 | $8,239.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $11,408.74
| Professional | | $7,503.37 | $7,503.37 | $11,408.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,371.58 / $10,860.29 / $10,860.29
| Professional | | $10,371.58 | $10,860.29 | $10,860.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,222.95 / $10,371.58 / $14,520.21
| Professional | | $6,222.95 | $10,371.58 | $14,520.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,192.06 / $8,239.32 / $11,408.74
| Professional | | $7,192.06 | $8,239.32 | $11,408.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,535.85 / $8,354.70 / $9,871.83
| Professional | | $4,535.85 | $8,354.70 | $9,871.83 |