- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,047.40 / $8,047.40 / $8,047.40
| Professional | | $8,047.40 | $8,047.40 | $8,047.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,396.43 / $17,396.43 / $17,396.43
| Facility | | $17,396.43 | $17,396.43 | $17,396.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,513.81 / $14,513.81 / $24,088.35
| Professional | | $14,513.81 | $14,513.81 | $24,088.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,898.50 / $22,930.36 / $22,930.36
| Professional | | $21,898.50 | $22,930.36 | $22,930.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,328.95 / $21,898.50 / $30,657.90
| Professional | | $15,328.95 | $21,898.50 | $30,657.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,290.56 / $17,396.43 / $24,088.35
| Professional | | $13,290.56 | $17,396.43 | $24,088.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,640.06 / $18,244.61 / $20,843.32
| Professional | | $17,640.06 | $18,244.61 | $20,843.32 |