- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.33 / $1,185.33 / $1,185.33
| Professional | | $1,185.33 | $1,185.33 | $1,185.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,926.50 / $2,926.50 / $2,926.50
| Facility | | $2,926.50 | $2,926.50 | $2,926.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $4,052.25
| Professional | | $2,425.11 | $2,425.11 | $4,052.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,683.86 / $3,857.44 / $3,857.44
| Professional | | $3,683.86 | $3,857.44 | $3,857.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.32 / $3,683.86 / $5,157.39
| Professional | | $2,210.32 | $3,683.86 | $5,157.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.71 / $2,926.50 / $4,052.25
| Professional | | $2,410.71 | $2,926.50 | $4,052.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.06 / $2,301.52 / $3,506.35
| Professional | | $1,611.06 | $2,301.52 | $3,506.35 |