- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.08 / $1,514.08 / $1,514.08
| Professional | | $1,514.08 | $1,514.08 | $1,514.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,091.11 / $4,091.11 / $4,091.11
| Facility | | $4,091.11 | $4,091.11 | $4,091.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $5,664.84
| Professional | | $3,001.57 | $3,001.57 | $5,664.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,149.85 / $5,392.51 / $5,392.51
| Professional | | $5,149.85 | $5,392.51 | $5,392.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,604.90 / $5,149.85 / $7,209.79
| Professional | | $3,604.90 | $5,149.85 | $7,209.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,291.83 / $4,091.11 / $5,664.84
| Professional | | $3,291.83 | $4,091.11 | $5,664.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,148.41 / $4,290.57 / $4,901.71
| Professional | | $4,148.41 | $4,290.57 | $4,901.71 |