- 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
- $1,568.36 / $1,568.36 / $1,568.36
| Professional | | $1,568.36 | $1,568.36 | $1,568.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.43 / $1,952.43 / $2,017.34
| Professional | | $1,952.43 | $1,952.43 | $2,017.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.77 / $2,478.53 / $3,064.09
| Professional | | $2,264.77 | $2,478.53 | $3,064.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.13 / $1,874.33 / $2,186.71
| Professional | | $1,718.13 | $1,874.33 | $2,186.71 |
- 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
- $1,593.18 / $1,984.62 / $2,587.85
| Professional | | $1,593.18 | $1,984.62 | $2,587.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,951.72 / $2,851.16
| Professional | | $29.27 | $1,951.72 | $2,851.16 |