- 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
- $1,893.50 / $2,019.84 / $2,434.34
| Professional | | $1,893.50 | $2,019.84 | $2,434.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,370.73 / $2,370.73 / $2,599.19
| Professional | | $2,370.73 | $2,370.73 | $2,599.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,101.98 / $3,394.78 / $4,196.80
| Professional | | $3,101.98 | $3,394.78 | $4,196.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.23 / $2,275.90 / $2,655.21
| Professional | | $2,086.23 | $2,275.90 | $2,655.21 |
- 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
- $1,934.51 / $2,444.78 / $3,173.78
| Professional | | $1,934.51 | $2,444.78 | $3,173.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,435.96 / $3,502.25
| Professional | | $29.27 | $2,435.96 | $3,502.25 |