- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.70 / $1,486.70 / $1,486.70
| Professional | | $1,486.70 | $1,486.70 | $1,486.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,402.66 / $3,402.66 / $3,402.66
| Facility | | $3,402.66 | $3,402.66 | $3,402.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.71 / $4,711.58 / $4,711.58
| Professional | | $2,282.71 | $4,711.58 | $4,711.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,283.25 / $4,485.08 / $4,485.08
| Professional | | $4,283.25 | $4,485.08 | $4,485.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,569.94 / $4,283.25 / $5,996.55
| Professional | | $2,569.94 | $4,283.25 | $5,996.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,788.97 / $3,402.66 / $4,711.58
| Professional | | $2,788.97 | $3,402.66 | $4,711.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.21 / $3,450.31 / $4,076.86
| Professional | | $1,873.21 | $3,450.31 | $4,076.86 |