- 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
- $1,812.18 / $1,812.18 / $1,812.18
| Professional | | $1,812.18 | $1,812.18 | $1,812.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.25 / $2,168.25 / $2,350.32
| Professional | | $2,168.25 | $2,168.25 | $2,350.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.66 / $2,773.90 / $3,429.24
| Professional | | $2,534.66 | $2,773.90 | $3,429.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.06 / $2,081.52 / $2,428.44
| Professional | | $1,908.06 | $2,081.52 | $2,428.44 |
- 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
- $1,769.29 / $2,227.15 / $2,892.75
| Professional | | $1,769.29 | $2,227.15 | $2,892.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,094.42 / $3,027.92
| Professional | | $29.27 | $2,094.42 | $3,027.92 |