- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.53 / $1,640.53 / $1,640.53
| Professional | | $1,640.53 | $1,640.53 | $1,640.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,371.89 / $3,371.89 / $3,371.89
| Facility | | $3,371.89 | $3,371.89 | $3,371.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $4,668.96
| Professional | | $2,741.63 | $2,741.63 | $4,668.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,244.51 / $4,444.51 / $4,444.51
| Professional | | $4,244.51 | $4,444.51 | $4,444.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.71 / $4,244.51 / $5,942.31
| Professional | | $2,546.71 | $4,244.51 | $5,942.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.35 / $3,968.62 / $4,668.96
| Professional | | $2,672.35 | $3,968.62 | $4,668.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,419.11 / $3,536.29 / $4,039.99
| Professional | | $3,419.11 | $3,536.29 | $4,039.99 |