- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.04 / $1,522.04 / $1,522.04
| Professional | | $1,522.04 | $1,522.04 | $1,522.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,860.54 / $3,860.54 / $3,860.54
| Facility | | $3,860.54 | $3,860.54 | $3,860.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.90 / $5,345.59 / $5,345.59
| Professional | | $2,117.90 | $5,345.59 | $5,345.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,859.63 / $5,088.62 / $5,088.62
| Professional | | $4,859.63 | $5,088.62 | $5,088.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,915.78 / $4,859.63 / $6,803.48
| Professional | | $2,915.78 | $4,859.63 | $6,803.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,587.58 / $3,860.54 / $5,345.59
| Professional | | $2,587.58 | $3,860.54 | $5,345.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.28 / $3,914.61 / $4,625.47
| Professional | | $2,125.28 | $3,914.61 | $4,625.47 |