- 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
- $5,429.54 / $5,429.54 / $5,897.07
| Professional | | $5,429.54 | $5,429.54 | $5,897.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,053.69 / $6,668.01 / $7,207.47
| Professional | | $6,053.69 | $6,668.01 | $7,207.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,556.39 / $8,489.83 / $10,018.00
| Professional | | $7,556.39 | $8,489.83 | $10,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,867.85 / $6,401.29 / $7,468.17
| Professional | | $5,867.85 | $6,401.29 | $7,468.17 |
- 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
- $5,441.10 / $6,753.44 / $9,123.06
| Professional | | $5,441.10 | $6,753.44 | $9,123.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $6,884.31 / $8,842.15
| Professional | | $29.27 | $6,884.31 | $8,842.15 |