- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.68 / $1,365.68 / $1,365.68
| Professional | | $1,365.68 | $1,365.68 | $1,365.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,952.26 / $2,952.26 / $2,952.26
| Facility | | $2,952.26 | $2,952.26 | $2,952.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $4,087.91
| Professional | | $2,463.07 | $2,463.07 | $4,087.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,716.28 / $3,891.39 / $3,891.39
| Professional | | $3,716.28 | $3,891.39 | $3,891.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,229.77 / $3,716.28 / $5,202.79
| Professional | | $2,229.77 | $3,716.28 | $5,202.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.48 / $2,952.26 / $4,087.91
| Professional | | $2,255.48 | $2,952.26 | $4,087.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,993.60 / $3,096.19 / $3,537.21
| Professional | | $2,993.60 | $3,096.19 | $3,537.21 |