- 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
- $1,413.01 / $1,413.01 / $1,413.01
| Professional | | $1,413.01 | $1,413.01 | $1,413.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.57 / $1,815.57 / $2,522.08
| Professional | | $1,815.57 | $1,815.57 | $2,522.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.60 / $2,679.73 / $3,312.82
| Professional | | $2,448.60 | $2,679.73 | $3,312.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.42 / $2,421.19 / $2,824.72
| Professional | | $2,219.42 | $2,421.19 | $2,824.72 |
- 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
- $2,058.01 / $2,522.08 / $3,325.73
| Professional | | $2,058.01 | $2,522.08 | $3,325.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,430.25 / $2,796.49
| Professional | | $29.27 | $2,430.25 | $2,796.49 |