- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.35 / $2,051.35 / $2,051.35
| Professional | | $2,051.35 | $2,051.35 | $2,051.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,719.86 / $5,719.86 / $5,719.86
| Facility | | $5,719.86 | $5,719.86 | $5,719.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $7,920.13
| Professional | | $4,052.23 | $4,052.23 | $7,920.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,200.12 / $7,539.39 / $7,539.39
| Professional | | $7,200.12 | $7,539.39 | $7,539.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,320.07 / $7,200.12 / $10,080.17
| Professional | | $4,320.07 | $7,200.12 | $10,080.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,261.57 / $5,719.86 / $7,920.13
| Professional | | $4,261.57 | $5,719.86 | $7,920.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,810.92 / $5,998.74 / $6,853.19
| Professional | | $4,810.92 | $5,998.74 | $6,853.19 |