- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,918.31 / $6,918.31
| Facility | | $2,818.38 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,630.27 / $3,467.37
| Professional | | $2,398.83 | $2,630.27 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $3,311.31
| Professional | | $2,344.23 | $2,951.21 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,715.35 / $4,466.84
| Professional | | $3,388.44 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $3,235.94
| Professional | | $2,290.87 | $2,630.27 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $3,981.07
| Professional | | $1,995.26 | $3,019.95 | $3,981.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $2,511.89 / $3,311.31
| Professional | | $29.51 | $2,511.89 | $3,311.31 |