- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,535.85 / $7,535.85 / $7,535.85
| Professional | | $7,535.85 | $7,535.85 | $7,535.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,438.18 / $16,438.18 / $16,438.18
| Facility | | $16,438.18 | $16,438.18 | $16,438.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,752.32 / $12,752.32 / $22,761.49
| Professional | | $12,752.32 | $12,752.32 | $22,761.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,692.25 / $21,667.28 / $21,667.28
| Professional | | $20,692.25 | $21,667.28 | $21,667.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,484.58 / $20,692.25 / $28,969.16
| Professional | | $14,484.58 | $20,692.25 | $28,969.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,614.49 / $19,347.25 / $22,761.49
| Professional | | $13,614.49 | $19,347.25 | $22,761.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,668.40 / $17,239.65 / $19,695.21
| Professional | | $16,668.40 | $17,239.65 | $19,695.21 |