- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.61 / $1,154.61 / $1,154.61
| Professional | | $1,154.61 | $1,154.61 | $1,154.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,495.98 / $2,495.98 / $2,495.98
| Facility | | $2,495.98 | $2,495.98 | $2,495.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.90 / $1,650.90 / $2,232.07
| Professional | | $1,650.90 | $1,650.90 | $2,232.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.98 / $2,613.60 / $2,613.60
| Professional | | $2,495.98 | $2,613.60 | $2,613.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.41 / $2,029.15 / $2,840.81
| Professional | | $1,420.41 | $2,029.15 | $2,840.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.95 / $1,945.95 / $1,945.95
| Facility | | $1,945.95 | $1,945.95 | $1,945.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.63 / $2,232.07 / $2,495.98
| Professional | | $1,544.63 | $2,232.07 | $2,495.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.56 / $1,690.57 / $1,931.37
| Professional | | $1,634.56 | $1,690.57 | $1,931.37 |