- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.76 / $1,345.76 / $1,345.76
| Professional | | $1,345.76 | $1,345.76 | $1,345.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,932.17 / $2,932.17 / $2,932.17
| Facility | | $2,932.17 | $2,932.17 | $2,932.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,375.33 / $2,375.33 / $4,060.08
| Professional | | $2,375.33 | $2,375.33 | $4,060.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,690.98 / $3,864.90 / $3,864.90
| Professional | | $3,690.98 | $3,864.90 | $3,864.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.59 / $3,690.98 / $5,167.37
| Professional | | $2,214.59 | $3,690.98 | $5,167.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.13 / $2,932.17 / $4,603.47
| Professional | | $2,175.13 | $2,932.17 | $4,603.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.20 / $2,306.00 / $3,513.13
| Professional | | $1,614.20 | $2,306.00 | $3,513.13 |