- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,267.96 / $5,267.96 / $5,267.96
| Professional | | $5,267.96 | $5,267.96 | $5,267.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,038.04 / $12,038.04 / $12,038.04
| Facility | | $12,038.04 | $12,038.04 | $12,038.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,418.01 / $9,418.01 / $16,668.73
| Professional | | $9,418.01 | $9,418.01 | $16,668.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,153.39 / $15,867.42 / $15,867.42
| Professional | | $15,153.39 | $15,867.42 | $15,867.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,092.03 / $15,153.39 / $21,214.75
| Professional | | $9,092.03 | $15,153.39 | $21,214.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,560.45 / $12,038.04 / $16,668.73
| Professional | | $10,560.45 | $12,038.04 | $16,668.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,627.10 / $12,206.63 / $14,423.23
| Professional | | $6,627.10 | $12,206.63 | $14,423.23 |