- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.49 / $1,573.49 / $1,573.49
| Professional | | $1,573.49 | $1,573.49 | $1,573.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,401.49 / $3,401.49 / $3,401.49
| Facility | | $3,401.49 | $3,401.49 | $3,401.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $4,709.95
| Professional | | $2,448.80 | $2,448.80 | $4,709.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,281.77 / $4,483.53 / $4,483.53
| Professional | | $4,281.77 | $4,483.53 | $4,483.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,569.06 / $4,281.77 / $5,994.48
| Professional | | $2,569.06 | $4,281.77 | $5,994.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,983.98 / $3,401.49 / $4,709.95
| Professional | | $2,983.98 | $3,401.49 | $4,709.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.56 / $3,449.13 / $4,075.46
| Professional | | $1,872.56 | $3,449.13 | $4,075.46 |