- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.66 / $1,176.66 / $1,176.66
| Professional | | $1,176.66 | $1,176.66 | $1,176.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,414.38 / $3,414.38 / $3,414.38
| Facility | | $3,414.38 | $3,414.38 | $3,414.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.62 / $4,727.79 / $4,727.79
| Professional | | $2,289.62 | $4,727.79 | $4,727.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,297.99 / $4,500.51 / $4,500.51
| Professional | | $4,297.99 | $4,500.51 | $4,500.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.79 / $4,297.99 / $6,017.19
| Professional | | $2,578.79 | $4,297.99 | $6,017.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.73 / $4,255.01 / $4,727.79
| Professional | | $2,202.73 | $4,255.01 | $4,727.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,879.66 / $2,685.23 / $4,090.90
| Professional | | $1,879.66 | $2,685.23 | $4,090.90 |