- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,251.16 / $6,251.16 / $6,251.16
| Professional | | $6,251.16 | $6,251.16 | $6,251.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,250.99 / $15,250.99 / $15,250.99
| Facility | | $15,250.99 | $15,250.99 | $15,250.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $21,117.62
| Professional | | $11,736.82 | $11,736.82 | $21,117.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,197.84 / $20,102.43 / $20,102.43
| Professional | | $19,197.84 | $20,102.43 | $20,102.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,518.70 / $19,197.84 / $26,876.98
| Professional | | $11,518.70 | $19,197.84 | $26,876.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,747.62 / $14,143.98 / $21,117.62
| Professional | | $10,747.62 | $14,143.98 | $21,117.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,395.87 / $15,464.58 / $18,272.80
| Professional | | $8,395.87 | $15,464.58 | $18,272.80 |