- 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
- $2,202.51 / $2,202.51 / $2,202.51
| Professional | | $2,202.51 | $2,202.51 | $2,202.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.40 / $2,432.40 / $2,876.50
| Professional | | $2,432.40 | $2,432.40 | $2,876.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,030.56 / $3,316.62 / $4,100.16
| Professional | | $3,030.56 | $3,316.62 | $4,100.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.51 / $2,335.10 / $2,724.29
| Professional | | $2,140.51 | $2,335.10 | $2,724.29 |
- 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
- $1,984.84 / $2,650.14 / $3,419.19
| Professional | | $1,984.84 | $2,650.14 | $3,419.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,665.07 / $3,935.92
| Professional | | $29.27 | $2,665.07 | $3,935.92 |