- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,014.68 / $4,014.68 / $4,014.68
| Facility | | $4,014.68 | $4,014.68 | $4,014.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $4,685.58
| Professional | | $456.28 | $3,282.89 | $4,685.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,851.50 / $6,127.22 / $7,612.35
| Professional | | $5,851.50 | $6,127.22 | $7,612.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,625.60 / $4,625.60 / $4,625.60
| Professional | | $4,625.60 | $4,625.60 | $4,625.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,676.92 / $4,014.68 / $4,766.60
| Professional | | $2,676.92 | $4,014.68 | $4,766.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,851.50 / $5,851.50 / $5,851.50
| Professional | | $5,851.50 | $5,851.50 | $5,851.50 |