- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.16 / $1,424.16 / $1,424.16
| Professional | | $1,424.16 | $1,424.16 | $1,424.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,333.06 / $4,333.06 / $4,333.06
| Facility | | $4,333.06 | $4,333.06 | $4,333.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $5,999.87
| Professional | | $3,141.52 | $3,141.52 | $5,999.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,454.43 / $5,711.44 / $5,711.44
| Professional | | $5,454.43 | $5,711.44 | $5,711.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,272.66 / $5,454.43 / $7,636.20
| Professional | | $3,272.66 | $5,454.43 | $7,636.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.14 / $4,333.06 / $5,999.87
| Professional | | $2,134.14 | $4,333.06 | $5,999.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.40 / $4,393.75 / $5,191.60
| Professional | | $2,385.40 | $4,393.75 | $5,191.60 |