- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.97 / $1,025.97 / $1,025.97
| Professional | | $1,025.97 | $1,025.97 | $1,025.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,430.67 / $2,430.67 / $2,430.67
| Facility | | $2,430.67 | $2,430.67 | $2,430.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $3,365.70
| Professional | | $2,119.51 | $2,119.51 | $3,365.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,059.73 / $3,203.90 / $3,203.90
| Professional | | $3,059.73 | $3,203.90 | $3,203.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.84 / $3,059.73 / $4,283.62
| Professional | | $1,835.84 | $3,059.73 | $4,283.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.79 / $3,029.13 / $3,365.70
| Professional | | $1,916.79 | $3,029.13 | $3,365.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.73 / $2,549.19 / $2,912.30
| Professional | | $2,464.73 | $2,549.19 | $2,912.30 |