- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.92 / $1,677.92 / $1,677.92
| Professional | | $1,677.92 | $1,677.92 | $1,677.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,514.98 / $5,514.98 / $5,514.98
| Facility | | $5,514.98 | $5,514.98 | $5,514.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $7,636.44
| Professional | | $2,853.06 | $2,853.06 | $7,636.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,942.22 / $7,269.34 / $7,269.34
| Professional | | $6,942.22 | $7,269.34 | $7,269.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,165.33 / $6,942.22 / $9,719.11
| Professional | | $4,165.33 | $6,942.22 | $9,719.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,410.06 / $5,514.98 / $7,636.44
| Professional | | $3,410.06 | $5,514.98 | $7,636.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,036.07 / $5,592.22 / $6,607.71
| Professional | | $3,036.07 | $5,592.22 | $6,607.71 |