- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.50 / $1,732.50 / $1,732.50
| Professional | | $1,732.50 | $1,732.50 | $1,732.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.23 / $3,745.23 / $3,745.23
| Facility | | $3,745.23 | $3,745.23 | $3,745.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $5,185.93
| Professional | | $2,886.72 | $2,886.72 | $5,185.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,714.47 / $4,936.63 / $4,936.63
| Professional | | $4,714.47 | $4,936.63 | $4,936.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,828.69 / $4,714.47 / $6,600.27
| Professional | | $2,828.69 | $4,714.47 | $6,600.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,861.31 / $3,745.23 / $5,185.93
| Professional | | $2,861.31 | $3,745.23 | $5,185.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,285.53 / $3,927.84 / $4,487.31
| Professional | | $3,285.53 | $3,927.84 | $4,487.31 |