- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.79 / $3,162.79 / $3,162.79
| Professional | | $3,162.79 | $3,162.79 | $3,162.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,164.51 / $6,164.51 / $6,164.51
| Facility | | $6,164.51 | $6,164.51 | $6,164.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,938.58 / $4,938.58 / $8,535.81
| Professional | | $4,938.58 | $4,938.58 | $8,535.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,759.83 / $8,125.47 / $8,125.47
| Professional | | $7,759.83 | $8,125.47 | $8,125.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,655.89 / $7,759.83 / $10,863.76
| Professional | | $4,655.89 | $7,759.83 | $10,863.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,407.87 / $6,164.51 / $8,535.81
| Professional | | $5,407.87 | $6,164.51 | $8,535.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,393.66 / $6,250.84 / $7,385.93
| Professional | | $3,393.66 | $6,250.84 | $7,385.93 |