- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.82 / $1,082.82 / $1,082.82
| Professional | | $1,082.82 | $1,082.82 | $1,082.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,340.78 / $2,340.78 / $2,340.78
| Facility | | $2,340.78 | $2,340.78 | $2,340.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $3,241.22
| Professional | | $1,952.91 | $1,952.91 | $3,241.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,946.56 / $3,085.40 / $3,085.40
| Professional | | $2,946.56 | $3,085.40 | $3,085.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.94 / $2,946.56 / $4,125.18
| Professional | | $1,767.94 | $2,946.56 | $4,125.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.46 / $2,340.78 / $3,241.22
| Professional | | $2,053.46 | $2,340.78 | $3,241.22 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.57 / $2,454.91 / $2,804.58
| Professional | | $2,373.57 | $2,454.91 | $2,804.58 |