- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.28 / $1,835.28 / $1,835.28
| Professional | | $1,835.28 | $1,835.28 | $1,835.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,145.50 / $4,145.50 / $4,145.50
| Facility | | $4,145.50 | $4,145.50 | $4,145.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,323.97 / $4,541.81 / $5,740.15
| Professional | | $3,323.97 | $4,541.81 | $5,740.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.52 / $1,231.52 / $1,231.52
| Professional | | $1,231.52 | $1,231.52 | $1,231.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,652.82 / $5,218.32 / $7,305.65
| Professional | | $3,652.82 | $5,218.32 | $7,305.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,545.90 / $4,879.13 / $5,740.15
| Professional | | $3,545.90 | $4,879.13 | $5,740.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,203.56 / $4,347.62 / $4,966.88
| Professional | | $4,203.56 | $4,347.62 | $4,966.88 |