- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,021.26 / $2,021.26 / $2,021.26
| Professional | | $2,021.26 | $2,021.26 | $2,021.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,224.71 / $4,224.71 / $4,224.71
| Facility | | $4,224.71 | $4,224.71 | $4,224.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $5,849.82
| Professional | | $2,802.84 | $2,802.84 | $5,849.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,318.02 / $5,568.61 / $5,568.61
| Professional | | $5,318.02 | $5,568.61 | $5,568.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,553.37 / $5,318.02 / $7,445.23
| Professional | | $3,553.37 | $5,318.02 | $7,445.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,424.44 / $4,224.71 / $5,849.82
| Professional | | $3,424.44 | $4,224.71 | $5,849.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,283.87 / $4,430.68 / $5,061.77
| Professional | | $4,283.87 | $4,430.68 | $5,061.77 |