- 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
- $1,719.60 / $1,719.60 / $1,719.60
| Professional | | $1,719.60 | $1,719.60 | $1,719.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.38 / $2,203.38 / $2,366.75
| Professional | | $2,203.38 | $2,203.38 | $2,366.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.73 / $2,805.74 / $3,468.60
| Professional | | $2,563.73 | $2,805.74 | $3,468.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,272.08 / $2,650.76
| Professional | | $2,082.73 | $2,272.08 | $2,650.76 |
- 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
- $1,931.27 / $2,366.75 / $3,167.33
| Professional | | $1,931.27 | $2,366.75 | $3,167.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,116.28 / $3,060.99
| Professional | | $29.27 | $2,116.28 | $3,060.99 |