- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,313.14 / $5,313.14 / $5,313.14
| Professional | | $5,313.14 | $5,313.14 | $5,313.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,129.43 / $13,129.43 / $13,129.43
| Facility | | $13,129.43 | $13,129.43 | $13,129.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,907.40 / $9,907.40 / $18,179.95
| Professional | | $9,907.40 | $9,907.40 | $18,179.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,527.23 / $17,305.99 / $17,305.99
| Professional | | $16,527.23 | $17,305.99 | $17,305.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,916.34 / $16,527.23 / $23,138.12
| Professional | | $9,916.34 | $16,527.23 | $23,138.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,037.78 / $13,129.43 / $18,179.95
| Professional | | $11,037.78 | $13,129.43 | $18,179.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,227.93 / $13,313.30 / $15,730.87
| Professional | | $7,227.93 | $13,313.30 | $15,730.87 |