- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.67 / $1,449.67 / $1,449.67
| Professional | | $1,449.67 | $1,449.67 | $1,449.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,225.87 / $5,225.87 / $5,225.87
| Facility | | $5,225.87 | $5,225.87 | $5,225.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $7,236.12
| Professional | | $2,481.10 | $2,481.10 | $7,236.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,578.29 / $6,888.26 / $6,888.26
| Professional | | $6,578.29 | $6,888.26 | $6,888.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,946.97 / $6,578.29 / $9,209.61
| Professional | | $3,946.97 | $6,578.29 | $9,209.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.65 / $2,600.65 / $2,668.77
| Facility | | $2,600.65 | $2,600.65 | $2,668.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.80 / $5,225.87 / $7,236.12
| Professional | | $2,554.80 | $5,225.87 | $7,236.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,395.42 / $5,480.67 / $6,261.32
| Professional | | $4,395.42 | $5,480.67 | $6,261.32 |