- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.48 / $2,268.48 / $2,268.48
| Professional | | $2,268.48 | $2,268.48 | $2,268.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,019.24 / $9,019.24 / $9,019.24
| Facility | | $9,019.24 | $9,019.24 | $9,019.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,865.01 / $4,865.01 / $12,488.67
| Professional | | $4,865.01 | $4,865.01 | $12,488.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,353.34 / $11,888.31 / $11,888.31
| Professional | | $11,353.34 | $11,888.31 | $11,888.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,812.00 / $11,353.34 / $15,894.68
| Professional | | $6,812.00 | $11,353.34 | $15,894.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,712.66 / $9,019.24 / $14,160.15
| Professional | | $4,712.66 | $9,019.24 | $14,160.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,965.21 / $9,145.54 / $10,806.29
| Professional | | $4,965.21 | $9,145.54 | $10,806.29 |