- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,048.54 / $7,048.54 / $7,048.54
| Professional | | $7,048.54 | $7,048.54 | $7,048.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,992.99 / $18,992.99 / $18,992.99
| Facility | | $18,992.99 | $18,992.99 | $18,992.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,847.37 / $13,847.37 / $26,299.06
| Professional | | $13,847.37 | $13,847.37 | $26,299.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,908.24 / $25,034.80 / $25,034.80
| Professional | | $23,908.24 | $25,034.80 | $25,034.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,344.94 / $23,908.24 / $33,471.54
| Professional | | $14,344.94 | $23,908.24 | $33,471.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,642.99 / $18,992.99 / $26,299.06
| Professional | | $14,642.99 | $18,992.99 | $26,299.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,455.89 / $19,258.98 / $22,756.23
| Professional | | $10,455.89 | $19,258.98 | $22,756.23 |