- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.88 / $1,525.14 / $1,525.14
| Professional | | $1,328.88 | $1,525.14 | $1,525.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.47 / $2,057.10 / $2,163.30
| Professional | | $1,762.47 | $2,057.10 | $2,163.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,408.05 / $2,705.52 / $20,261.00
| Professional | | $2,408.05 | $2,705.52 | $20,261.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.25 / $1,974.82 / $2,303.94
| Professional | | $1,810.25 | $1,974.82 | $2,303.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.59 / $2,167.82 / $2,743.97
| Professional | | $1,678.59 | $2,167.82 | $2,743.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.02 / $2,109.44 / $2,270.33
| Professional | | $286.02 | $2,109.44 | $2,270.33 |