- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,444.46 / $2,444.46 / $2,444.46
| Professional | | $2,444.46 | $2,444.46 | $2,444.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,825.79 / $8,825.79 / $8,825.79
| Facility | | $8,825.79 | $8,825.79 | $8,825.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $12,220.85
| Professional | | $4,366.38 | $4,366.38 | $12,220.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,109.86 / $11,633.36 / $11,633.36
| Professional | | $11,109.86 | $11,633.36 | $11,633.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,665.92 / $11,109.86 / $15,553.80
| Professional | | $6,665.92 | $11,109.86 | $15,553.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,178.07 / $8,825.79 / $12,220.85
| Professional | | $5,178.07 | $8,825.79 | $12,220.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,858.71 / $8,949.40 / $10,574.53
| Professional | | $4,858.71 | $8,949.40 | $10,574.53 |