- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,433.02 / $6,433.02 / $6,433.02
| Professional | | $6,433.02 | $6,433.02 | $6,433.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,171.80 / $16,171.80 / $16,171.80
| Facility | | $16,171.80 | $16,171.80 | $16,171.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,562.99 / $12,562.99 / $22,392.63
| Professional | | $12,562.99 | $12,562.99 | $22,392.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,356.93 / $21,316.16 / $21,316.16
| Professional | | $20,356.93 | $21,316.16 | $21,316.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,214.16 / $20,356.93 / $28,499.72
| Professional | | $12,214.16 | $20,356.93 | $28,499.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,504.15 / $16,171.80 / $22,392.63
| Professional | | $11,504.15 | $16,171.80 | $22,392.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,902.81 / $16,398.28 / $19,376.04
| Professional | | $8,902.81 | $16,398.28 | $19,376.04 |