- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.29 / $1,026.29 / $1,026.29
| Professional | | $1,026.29 | $1,026.29 | $1,026.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,636.40 / $3,636.40 / $3,636.40
| Facility | | $3,636.40 | $3,636.40 | $3,636.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $5,035.21
| Professional | | $2,283.76 | $2,283.76 | $5,035.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,577.46 / $4,793.14 / $4,793.14
| Professional | | $4,577.46 | $4,793.14 | $4,793.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.48 / $4,577.46 / $6,408.44
| Professional | | $2,746.48 | $4,577.46 | $6,408.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,045.66 / $3,636.40 / $5,035.21
| Professional | | $2,045.66 | $3,636.40 | $5,035.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,687.32 / $3,813.69 / $4,356.89
| Professional | | $3,687.32 | $3,813.69 | $4,356.89 |