- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.47 / $1,194.47 / $1,194.47
| Professional | | $1,194.47 | $1,194.47 | $1,194.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,046.78 / $3,046.78 / $3,046.78
| Facility | | $3,046.78 | $3,046.78 | $3,046.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.27 / $1,523.27 / $4,218.78
| Professional | | $1,523.27 | $1,523.27 | $4,218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,835.25 / $4,015.97 / $4,015.97
| Professional | | $3,835.25 | $4,015.97 | $4,015.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.15 / $3,835.25 / $5,369.35
| Professional | | $2,301.15 | $3,835.25 | $5,369.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.09 / $3,046.78 / $4,218.78
| Professional | | $1,751.09 | $3,046.78 | $4,218.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.29 / $3,089.44 / $3,650.45
| Professional | | $1,677.29 | $3,089.44 | $3,650.45 |