- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,981.76 / $4,981.76 / $4,981.76
| Professional | | $4,981.76 | $4,981.76 | $4,981.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,545.78 / $8,545.78 / $8,545.78
| Facility | | $8,545.78 | $8,545.78 | $8,545.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,732.85 / $8,732.85 / $11,833.10
| Professional | | $8,732.85 | $8,732.85 | $11,833.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,757.36 / $11,264.25 / $11,264.25
| Professional | | $10,757.36 | $11,264.25 | $11,264.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,454.42 / $10,757.36 / $15,060.30
| Professional | | $6,454.42 | $10,757.36 | $15,060.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,496.85 / $9,224.40 / $13,416.83
| Professional | | $7,496.85 | $9,224.40 | $13,416.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,704.57 / $8,665.45 / $10,239.02
| Professional | | $4,704.57 | $8,665.45 | $10,239.02 |