- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.85 / $1,131.85 / $1,131.85
| Professional | | $1,131.85 | $1,131.85 | $1,131.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.55 / $2,155.55 / $2,155.55
| Facility | | $2,155.55 | $2,155.55 | $2,155.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,964.43 / $1,964.43 / $2,984.72
| Professional | | $1,964.43 | $1,964.43 | $2,984.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.38 / $2,841.23 / $2,841.23
| Professional | | $2,713.38 | $2,841.23 | $2,841.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.03 / $2,713.38 / $3,798.73
| Professional | | $1,628.03 | $2,713.38 | $3,798.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.51 / $2,155.55 / $2,984.72
| Professional | | $1,353.51 | $2,155.55 | $2,984.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.65 / $2,185.73 / $2,582.64
| Professional | | $1,186.65 | $2,185.73 | $2,582.64 |