- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.92 / $1,681.92 / $1,681.92
| Professional | | $1,681.92 | $1,681.92 | $1,681.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,804.19 / $5,804.19 / $5,804.19
| Facility | | $5,804.19 | $5,804.19 | $5,804.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,532.34 / $3,532.34 / $8,036.91
| Professional | | $3,532.34 | $3,532.34 | $8,036.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,306.28 / $7,650.55 / $7,650.55
| Professional | | $7,306.28 | $7,650.55 | $7,650.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,383.77 / $7,306.28 / $10,228.79
| Professional | | $4,383.77 | $7,306.28 | $10,228.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,234.62 / $5,804.19 / $8,036.91
| Professional | | $3,234.62 | $5,804.19 | $8,036.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,195.28 / $5,885.48 / $6,954.23
| Professional | | $3,195.28 | $5,885.48 | $6,954.23 |