- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,102.62 / $4,102.62 / $4,102.62
| Professional | | $4,102.62 | $4,102.62 | $4,102.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,035.89 / $9,035.89 / $9,035.89
| Facility | | $9,035.89 | $9,035.89 | $9,035.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,136.27 / $8,136.27 / $12,511.76
| Professional | | $8,136.27 | $8,136.27 | $12,511.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,374.33 / $11,910.29 / $11,910.29
| Professional | | $11,374.33 | $11,910.29 | $11,910.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,824.60 / $11,374.33 / $15,924.06
| Professional | | $6,824.60 | $11,374.33 | $15,924.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,450.53 / $9,035.89 / $12,511.76
| Professional | | $7,450.53 | $9,035.89 | $12,511.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,974.39 / $9,162.44 / $10,826.26
| Professional | | $4,974.39 | $9,162.44 | $10,826.26 |