- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.60 / $1,143.60 / $1,143.60
| Professional | | $1,143.60 | $1,143.60 | $1,143.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,226.37 / $3,226.37 / $3,226.37
| Facility | | $3,226.37 | $3,226.37 | $3,226.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.18 / $1,769.18 / $4,467.46
| Professional | | $1,769.18 | $1,769.18 | $4,467.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,061.33 / $4,252.70 / $4,252.70
| Professional | | $4,061.33 | $4,252.70 | $4,252.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.80 / $4,061.33 / $5,685.86
| Professional | | $2,436.80 | $4,061.33 | $5,685.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.52 / $3,226.37 / $4,467.46
| Professional | | $2,161.52 | $3,226.37 | $4,467.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.15 / $2,537.36 / $3,865.63
| Professional | | $1,776.15 | $2,537.36 | $3,865.63 |