- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.45 / $1,411.45 / $1,411.45
| Professional | | $1,411.45 | $1,411.45 | $1,411.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,347.39 / $4,347.39 / $4,347.39
| Facility | | $4,347.39 | $4,347.39 | $4,347.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $6,019.72
| Professional | | $2,479.82 | $2,479.82 | $6,019.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,472.47 / $5,730.33 / $5,730.33
| Professional | | $5,472.47 | $5,730.33 | $5,730.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,283.48 / $5,472.47 / $7,661.46
| Professional | | $3,283.48 | $5,472.47 | $7,661.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.48 / $4,347.39 / $6,019.72
| Professional | | $2,583.48 | $4,347.39 | $6,019.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.30 / $4,408.28 / $5,208.78
| Professional | | $2,393.30 | $4,408.28 | $5,208.78 |