- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.22 / $1,248.22 / $1,248.22
| Professional | | $1,248.22 | $1,248.22 | $1,248.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,116.14 / $4,116.14 / $4,116.14
| Facility | | $4,116.14 | $4,116.14 | $4,116.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,561.34 / $5,699.52
| Professional | | $2,561.34 | $2,561.34 | $5,699.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,181.38 / $5,425.53 / $5,425.53
| Professional | | $5,181.38 | $5,425.53 | $5,425.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.83 / $5,181.38 / $7,253.93
| Professional | | $3,108.83 | $5,181.38 | $7,253.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.60 / $4,116.14 / $5,699.52
| Professional | | $2,460.60 | $4,116.14 | $5,699.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,265.98 / $4,173.79 / $4,931.72
| Professional | | $2,265.98 | $4,173.79 | $4,931.72 |