- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.53 / $2,303.53 / $2,303.53
| Professional | | $2,303.53 | $2,303.53 | $2,303.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,402.33 / $5,402.33 / $5,402.33
| Facility | | $5,402.33 | $5,402.33 | $5,402.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,798.08 / $3,798.08 / $7,480.45
| Professional | | $3,798.08 | $3,798.08 | $7,480.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,800.41 / $7,120.85 / $7,120.85
| Professional | | $6,800.41 | $7,120.85 | $7,120.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,080.25 / $6,800.41 / $9,520.57
| Professional | | $4,080.25 | $6,800.41 | $9,520.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,589.10 / $5,402.33 / $7,480.45
| Professional | | $3,589.10 | $5,402.33 | $7,480.45 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,974.05 / $5,477.99 / $6,472.74
| Professional | | $2,974.05 | $5,477.99 | $6,472.74 |