- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,934.23 / $6,725.46 / $8,631.60
| Facility | | $5,934.23 | $6,725.46 | $8,631.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,812.29 / $3,812.29 / $3,812.29
| Professional | | $3,812.29 | $3,812.29 | $3,812.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,046.79 / $8,631.60 / $8,631.60
| Professional | | $4,046.79 | $8,631.60 | $8,631.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,534.44 / $10,233.27 / $11,319.99
| Professional | | $8,534.44 | $10,233.27 | $11,319.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,912.30 / $8,631.60 / $10,070.20
| Professional | | $7,912.30 | $8,631.60 | $10,070.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,193.00 / $8,631.60 / $10,789.50
| Professional | | $7,193.00 | $8,631.60 | $10,789.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,114.05 / $9,710.54 / $16,184.25
| Professional | | $6,114.05 | $9,710.54 | $16,184.25 |