- 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
- $2,639.25 / $2,639.25 / $2,639.25
| Professional | | $2,639.25 | $2,639.25 | $2,639.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,117.46 / $3,117.46 / $3,436.33
| Professional | | $3,117.46 | $3,117.46 | $3,436.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,694.83 / $4,043.59 / $4,998.89
| Professional | | $3,694.83 | $4,043.59 | $4,998.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.37 / $2,992.76 / $3,491.56
| Professional | | $2,743.37 | $2,992.76 | $3,491.56 |
- 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
- $2,543.85 / $3,222.83 / $4,179.68
| Professional | | $2,543.85 | $3,222.83 | $4,179.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,607.27 / $3,764.88
| Professional | | $29.27 | $2,607.27 | $3,764.88 |