- 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
- $1,845.81 / $1,845.81 / $1,845.81
| Professional | | $1,845.81 | $1,845.81 | $1,845.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.25 / $2,210.25 / $2,404.60
| Professional | | $2,210.25 | $2,210.25 | $2,404.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,590.51 / $2,835.04 / $3,504.81
| Professional | | $2,590.51 | $2,835.04 | $3,504.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.02 / $2,121.84 / $2,475.48
| Professional | | $1,945.02 | $2,121.84 | $2,475.48 |
- 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
- $1,803.56 / $2,276.26 / $2,956.35
| Professional | | $1,803.56 | $2,276.26 | $2,956.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,059.01 / $2,960.60
| Professional | | $29.27 | $2,059.01 | $2,960.60 |