- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.04 / $1,304.04 / $1,304.04
| Professional | | $1,304.04 | $1,304.04 | $1,304.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,725.63 / $2,725.63 / $2,725.63
| Facility | | $2,725.63 | $2,725.63 | $2,725.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.29 / $3,774.12 / $3,774.12
| Professional | | $1,808.29 | $3,774.12 | $3,774.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,431.02 / $3,592.69 / $3,592.69
| Professional | | $3,431.02 | $3,592.69 | $3,592.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,292.50 / $3,431.02 / $4,803.43
| Professional | | $2,292.50 | $3,431.02 | $4,803.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.32 / $2,725.63 / $3,774.12
| Professional | | $2,209.32 | $2,725.63 | $3,774.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.80 / $2,858.53 / $3,265.70
| Professional | | $2,763.80 | $2,858.53 | $3,265.70 |