- 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
- $1,899.45 / $1,899.45 / $1,899.45
| Professional | | $1,899.45 | $1,899.45 | $1,899.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.33 / $2,261.33 / $2,484.07
| Professional | | $2,261.33 | $2,261.33 | $2,484.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,659.59 / $2,910.64 / $3,598.27
| Professional | | $2,659.59 | $2,910.64 | $3,598.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.97 / $2,170.87 / $2,532.67
| Professional | | $1,989.97 | $2,170.87 | $2,532.67 |
- 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
- $1,845.24 / $2,347.36 / $3,041.49
| Professional | | $1,845.24 | $2,347.36 | $3,041.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,239.17 / $3,349.18
| Professional | | $29.27 | $2,239.17 | $3,349.18 |