- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.90 / $1,404.90 / $1,404.90
| Professional | | $1,404.90 | $1,404.90 | $1,404.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,811.94 / $5,811.94 / $5,811.94
| Facility | | $5,811.94 | $5,811.94 | $5,811.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $8,047.63
| Professional | | $3,297.39 | $3,297.39 | $8,047.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,316.03 / $7,660.76 / $7,660.76
| Professional | | $7,316.03 | $7,660.76 | $7,660.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,389.62 / $7,316.03 / $10,242.44
| Professional | | $4,389.62 | $7,316.03 | $10,242.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,178.74 / $5,811.94 / $8,047.63
| Professional | | $3,178.74 | $5,811.94 | $8,047.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,199.56 / $5,893.33 / $6,963.51
| Professional | | $3,199.56 | $5,893.33 | $6,963.51 |