- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.72 / $1,684.72 / $1,684.72
| Professional | | $1,684.72 | $1,684.72 | $1,684.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,822.83 / $5,822.83 / $5,822.83
| Facility | | $5,822.83 | $5,822.83 | $5,822.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $8,062.70
| Professional | | $3,670.30 | $3,670.30 | $8,062.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,329.73 / $7,675.11 / $7,675.11
| Professional | | $7,329.73 | $7,675.11 | $7,675.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,397.84 / $7,329.73 / $10,261.62
| Professional | | $4,397.84 | $7,329.73 | $10,261.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,499.92 / $7,256.43 / $8,062.70
| Professional | | $3,499.92 | $7,256.43 | $8,062.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.55 / $5,904.38 / $6,976.55
| Professional | | $3,205.55 | $5,904.38 | $6,976.55 |