- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,599.72 / $4,599.72 / $4,599.72
| Professional | | $4,599.72 | $4,599.72 | $4,599.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,399.67 / $10,399.67 / $10,399.67
| Facility | | $10,399.67 | $10,399.67 | $10,399.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,077.06 / $9,077.06 / $14,400.13
| Professional | | $9,077.06 | $9,077.06 | $14,400.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,091.03 / $13,707.88 / $13,707.88
| Professional | | $13,091.03 | $13,707.88 | $13,707.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,854.62 / $13,091.03 / $18,327.43
| Professional | | $7,854.62 | $13,091.03 | $18,327.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,123.17 / $10,399.67 / $14,400.13
| Professional | | $9,123.17 | $10,399.67 | $14,400.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,725.15 / $10,545.32 / $12,460.24
| Professional | | $5,725.15 | $10,545.32 | $12,460.24 |