- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.20 / $1,191.20 / $1,191.20
| Professional | | $1,191.20 | $1,191.20 | $1,191.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,300.97 / $3,300.97 / $3,300.97
| Facility | | $3,300.97 | $3,300.97 | $3,300.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.02 / $2,125.02 / $4,570.78
| Professional | | $2,125.02 | $2,125.02 | $4,570.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,155.25 / $4,351.05 / $4,351.05
| Professional | | $4,155.25 | $4,351.05 | $4,351.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.15 / $4,155.25 / $5,817.35
| Professional | | $2,493.15 | $4,155.25 | $5,817.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.19 / $3,300.97 / $4,570.78
| Professional | | $2,126.19 | $3,300.97 | $4,570.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.22 / $3,347.20 / $3,955.03
| Professional | | $1,817.22 | $3,347.20 | $3,955.03 |