- 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
- $1,414.96 / $1,414.96 / $1,414.96
| Professional | | $1,414.96 | $1,414.96 | $1,414.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.13 / $1,701.13 / $1,832.06
| Professional | | $1,701.13 | $1,701.13 | $1,832.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.55 / $2,159.83 / $2,670.09
| Professional | | $1,973.55 | $2,159.83 | $2,670.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.99 / $1,633.08 / $1,905.26
| Professional | | $1,496.99 | $1,633.08 | $1,905.26 |
- 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
- $1,388.12 / $1,734.30 / $2,257.46
| Professional | | $1,388.12 | $1,734.30 | $2,257.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,516.86 / $2,300.02
| Professional | | $29.27 | $1,516.86 | $2,300.02 |