- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.21 / $1,770.21 / $1,770.21
| Professional | | $1,770.21 | $1,770.21 | $1,770.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,826.75 / $3,826.75 / $3,826.75
| Facility | | $3,826.75 | $3,826.75 | $3,826.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,801.20 / $5,298.80 / $5,298.80
| Professional | | $2,801.20 | $5,298.80 | $5,298.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,817.09 / $5,044.07 / $5,044.07
| Professional | | $4,817.09 | $5,044.07 | $5,044.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,890.25 / $4,817.09 / $6,743.93
| Professional | | $2,890.25 | $4,817.09 | $6,743.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.05 / $3,826.75 / $5,298.80
| Professional | | $3,357.05 | $3,826.75 | $5,298.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,880.34 / $4,013.33 / $4,584.97
| Professional | | $3,880.34 | $4,013.33 | $4,584.97 |