- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.51 / $2,147.51 / $2,147.51
| Professional | | $2,147.51 | $2,147.51 | $2,147.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,521.38 / $4,521.38 / $4,521.38
| Facility | | $4,521.38 | $4,521.38 | $4,521.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $6,260.61
| Professional | | $2,780.72 | $2,780.72 | $6,260.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,691.46 / $5,959.64 / $5,959.64
| Professional | | $5,691.46 | $5,959.64 | $5,959.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,414.88 / $5,691.46 / $7,968.04
| Professional | | $3,414.88 | $5,691.46 | $7,968.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,700.21 / $4,521.38 / $6,260.61
| Professional | | $3,700.21 | $4,521.38 | $6,260.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,489.09 / $4,584.68 / $5,417.22
| Professional | | $2,489.09 | $4,584.68 | $5,417.22 |