- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.74 / $1,450.74 / $1,450.74
| Professional | | $1,450.74 | $1,450.74 | $1,450.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,032.28 / $3,032.28 / $3,032.28
| Facility | | $3,032.28 | $3,032.28 | $3,032.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,861.13 / $2,861.13 / $4,198.71
| Professional | | $2,861.13 | $2,861.13 | $4,198.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,817.01 / $3,996.87 / $3,996.87
| Professional | | $3,817.01 | $3,996.87 | $3,996.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.21 / $3,817.01 / $5,343.81
| Professional | | $2,290.21 | $3,817.01 | $5,343.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.32 / $3,032.28 / $4,198.71
| Professional | | $1,896.32 | $3,032.28 | $4,198.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,074.74 / $3,180.12 / $3,633.09
| Professional | | $3,074.74 | $3,180.12 | $3,633.09 |