- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.55 / $1,302.55 / $1,302.55
| Professional | | $1,302.55 | $1,302.55 | $1,302.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,356.42 / $4,356.42 / $4,356.42
| Facility | | $4,356.42 | $4,356.42 | $4,356.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $6,032.20
| Professional | | $2,482.86 | $2,482.86 | $6,032.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,483.82 / $5,742.22 / $5,742.22
| Professional | | $5,483.82 | $5,742.22 | $5,742.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,290.29 / $5,483.82 / $7,677.35
| Professional | | $3,290.29 | $5,483.82 | $7,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.50 / $2,182.50 / $2,239.67
| Facility | | $2,182.50 | $2,182.50 | $2,239.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.40 / $4,356.42 / $6,032.20
| Professional | | $2,527.40 | $4,356.42 | $6,032.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.26 / $4,417.42 / $5,219.58
| Professional | | $2,398.26 | $4,417.42 | $5,219.58 |