- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.22 / $1,375.22 / $1,375.22
| Professional | | $1,375.22 | $1,375.22 | $1,375.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,157.00 / $3,157.00 / $3,157.00
| Facility | | $3,157.00 | $3,157.00 | $3,157.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $4,371.41
| Professional | | $2,677.88 | $2,677.88 | $4,371.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,974.01 / $4,161.27 / $4,161.27
| Professional | | $3,974.01 | $4,161.27 | $4,161.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.41 / $3,974.01 / $5,563.61
| Professional | | $2,384.41 | $3,974.01 | $5,563.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.50 / $3,157.00 / $4,956.47
| Professional | | $2,769.50 | $3,157.00 | $4,956.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.97 / $3,201.21 / $3,782.52
| Professional | | $1,737.97 | $3,201.21 | $3,782.52 |