- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.78 / $2,055.78 / $2,055.78
| Professional | | $2,055.78 | $2,055.78 | $2,055.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,724.82 / $6,724.82 / $6,724.82
| Facility | | $6,724.82 | $6,724.82 | $6,724.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $9,311.68
| Professional | | $3,943.38 | $3,943.38 | $9,311.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,465.16 / $8,864.04 / $8,864.04
| Professional | | $8,465.16 | $8,864.04 | $8,864.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,079.10 / $8,465.16 / $11,851.22
| Professional | | $5,079.10 | $8,465.16 | $11,851.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,010.55 / $6,724.82 / $9,311.68
| Professional | | $4,010.55 | $6,724.82 | $9,311.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,702.10 / $6,819.00 / $8,057.27
| Professional | | $3,702.10 | $6,819.00 | $8,057.27 |