- 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
- $2,508.75 / $2,508.75 / $2,508.75
| Professional | | $2,508.75 | $2,508.75 | $2,508.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,040.11 / $3,040.11 / $3,270.08
| Professional | | $3,040.11 | $3,040.11 | $3,270.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,536.63 / $3,870.46 / $4,784.85
| Professional | | $3,536.63 | $3,870.46 | $4,784.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.30 / $2,918.51 / $3,404.93
| Professional | | $2,675.30 | $2,918.51 | $3,404.93 |
- 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
- $2,480.73 / $3,040.11 / $4,058.60
| Professional | | $2,480.73 | $3,040.11 | $4,058.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,237.53 / $3,343.14
| Professional | | $29.27 | $2,237.53 | $3,343.14 |