- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.60 / $1,272.60 / $1,272.60
| Professional | | $1,272.60 | $1,272.60 | $1,272.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,322.39 / $3,322.39 / $3,322.39
| Facility | | $3,322.39 | $3,322.39 | $3,322.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,782.58 / $4,600.39 / $4,600.39
| Professional | | $2,782.58 | $4,600.39 | $4,600.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,182.18 / $4,379.24 / $4,379.24
| Professional | | $4,182.18 | $4,379.24 | $4,379.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,509.31 / $4,182.18 / $5,855.05
| Professional | | $2,509.31 | $4,182.18 | $5,855.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.96 / $3,322.39 / $4,600.39
| Professional | | $2,589.96 | $3,322.39 | $4,600.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.02 / $2,612.89 / $3,980.66
| Professional | | $1,829.02 | $2,612.89 | $3,980.66 |