- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,994.52 / $1,994.52 / $1,994.52
| Professional | | $1,994.52 | $1,994.52 | $1,994.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,373.65 / $5,373.65 / $5,373.65
| Facility | | $5,373.65 | $5,373.65 | $5,373.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $7,440.77
| Professional | | $3,813.78 | $3,813.78 | $7,440.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,764.34 / $7,083.08 / $7,083.08
| Professional | | $6,764.34 | $7,083.08 | $7,083.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,058.60 / $6,764.34 / $9,470.08
| Professional | | $4,058.60 | $6,764.34 | $9,470.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,413.82 / $5,373.65 / $7,440.77
| Professional | | $3,413.82 | $5,373.65 | $7,440.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.26 / $5,448.92 / $6,438.40
| Professional | | $2,958.26 | $5,448.92 | $6,438.40 |