- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.05 / $1,099.05 / $1,099.05
| Professional | | $1,099.05 | $1,099.05 | $1,099.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,971.59 / $4,971.59 / $4,971.59
| Facility | | $4,971.59 | $4,971.59 | $4,971.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $6,884.01
| Professional | | $2,017.28 | $2,017.28 | $6,884.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,258.19 / $6,553.08 / $6,553.08
| Professional | | $6,258.19 | $6,553.08 | $6,553.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,754.91 / $6,258.19 / $8,761.46
| Professional | | $3,754.91 | $6,258.19 | $8,761.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.66 / $4,971.59 / $6,884.01
| Professional | | $2,464.66 | $4,971.59 | $6,884.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,736.92 / $5,041.21 / $5,956.64
| Professional | | $2,736.92 | $5,041.21 | $5,956.64 |