- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.72 / $1,630.72 / $1,630.72
| Professional | | $1,630.72 | $1,630.72 | $1,630.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,525.22 / $3,525.22 / $3,525.22
| Facility | | $3,525.22 | $3,525.22 | $3,525.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,941.06 / $4,881.27 / $4,881.27
| Professional | | $2,941.06 | $4,881.27 | $4,881.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,437.52 / $4,646.62 / $4,646.62
| Professional | | $4,437.52 | $4,646.62 | $4,646.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,662.51 / $4,437.52 / $6,212.53
| Professional | | $2,662.51 | $4,437.52 | $6,212.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,379.79 / $3,525.22 / $4,881.27
| Professional | | $2,379.79 | $3,525.22 | $4,881.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,574.59 / $3,697.10 / $4,223.70
| Professional | | $3,574.59 | $3,697.10 | $4,223.70 |