- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.40 / $1,867.40 / $1,867.40
| Professional | | $1,867.40 | $1,867.40 | $1,867.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.01 / $5,248.01 / $5,248.01
| Facility | | $5,248.01 | $5,248.01 | $5,248.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $7,266.78
| Professional | | $3,006.81 | $3,006.81 | $7,266.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.16 / $6,917.44 / $6,917.44
| Professional | | $6,606.16 | $6,917.44 | $6,917.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,963.70 / $6,606.16 / $9,248.62
| Professional | | $3,963.70 | $6,606.16 | $9,248.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.80 / $5,248.01 / $7,266.78
| Professional | | $2,547.80 | $5,248.01 | $7,266.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,889.10 / $5,321.51 / $6,287.85
| Professional | | $2,889.10 | $5,321.51 | $6,287.85 |