- 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
- $1,306.52 / $1,377.16 / $1,377.16
| Professional | | $1,306.52 | $1,377.16 | $1,377.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.88 / $1,712.88 / $1,782.14
| Professional | | $1,712.88 | $1,712.88 | $1,782.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.65 / $2,261.71 / $2,796.05
| Professional | | $2,066.65 | $2,261.71 | $2,796.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.28 / $1,710.85 / $1,995.99
| Professional | | $1,568.28 | $1,710.85 | $1,995.99 |
- 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
- $1,454.22 / $1,825.15 / $2,375.33
| Professional | | $1,454.22 | $1,825.15 | $2,375.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,828.62 / $2,706.15
| Professional | | $29.27 | $1,828.62 | $2,706.15 |