- 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
- $1,926.08 / $1,926.08 / $1,926.08
| Professional | | $1,926.08 | $1,926.08 | $1,926.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.76 / $2,319.76 / $2,491.12
| Professional | | $2,319.76 | $2,319.76 | $2,491.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,658.49 / $2,909.42 / $3,596.77
| Professional | | $2,658.49 | $2,909.42 | $3,596.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.39 / $2,226.96 / $2,598.13
| Professional | | $2,041.39 | $2,226.96 | $2,598.13 |
- 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
- $1,892.93 / $2,376.11 / $3,090.63
| Professional | | $1,892.93 | $2,376.11 | $3,090.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,321.75 / $3,267.68
| Professional | | $29.27 | $2,321.75 | $3,267.68 |