- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.27 / $1,121.27 / $1,121.27
| Professional | | $1,121.27 | $1,121.27 | $1,121.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,265.29 / $2,265.29 / $2,265.29
| Facility | | $2,265.29 | $2,265.29 | $2,265.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.63 / $1,665.63 / $3,136.67
| Professional | | $1,665.63 | $1,665.63 | $3,136.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,851.52 / $2,985.88 / $2,985.88
| Professional | | $2,851.52 | $2,985.88 | $2,985.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.91 / $2,851.52 / $3,992.13
| Professional | | $1,710.91 | $2,851.52 | $3,992.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.04 / $2,265.29 / $3,556.49
| Professional | | $1,747.04 | $2,265.29 | $3,556.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.06 / $2,297.01 / $2,714.12
| Professional | | $1,247.06 | $2,297.01 | $2,714.12 |