- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.26 / $1,130.26 / $1,130.26
| Professional | | $1,130.26 | $1,130.26 | $1,130.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,347.37 / $2,347.37 / $2,347.37
| Facility | | $2,347.37 | $2,347.37 | $2,347.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,277.46 / $3,250.34
| Professional | | $1,277.46 | $1,277.46 | $3,250.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,954.85 / $3,094.08 / $3,094.08
| Professional | | $2,954.85 | $3,094.08 | $3,094.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.91 / $2,954.85 / $4,136.79
| Professional | | $1,772.91 | $2,954.85 | $4,136.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.70 / $2,347.37 / $3,250.34
| Professional | | $1,436.70 | $2,347.37 | $3,250.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.26 / $2,380.25 / $2,812.48
| Professional | | $1,292.26 | $2,380.25 | $2,812.48 |