- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,398.63 / $4,398.63 / $4,398.63
| Professional | | $4,398.63 | $4,398.63 | $4,398.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,073.89 / $10,073.89 / $10,073.89
| Facility | | $10,073.89 | $10,073.89 | $10,073.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,121.18 / $13,949.03 / $13,949.03
| Professional | | $8,121.18 | $13,949.03 | $13,949.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,680.94 / $13,278.47 / $13,278.47
| Professional | | $12,680.94 | $13,278.47 | $13,278.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,608.56 / $12,680.94 / $17,753.32
| Professional | | $7,608.56 | $12,680.94 | $17,753.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,436.71 / $10,073.89 / $13,949.03
| Professional | | $7,436.71 | $10,073.89 | $13,949.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,545.80 / $10,214.96 / $12,069.91
| Professional | | $5,545.80 | $10,214.96 | $12,069.91 |