- 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
- $2,602.29 / $2,943.45 / $4,530.54
| Professional | | $2,602.29 | $2,943.45 | $4,530.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.26 / $3,695.54 / $7,202.49
| Professional | | $2,808.26 | $3,695.54 | $7,202.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,982.52 / $4,474.47 / $5,145.64
| Professional | | $3,982.52 | $4,474.47 | $5,145.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.82 / $3,547.72 / $4,139.00
| Professional | | $3,133.82 | $3,547.72 | $4,139.00 |
- 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
- $2,761.14 / $3,695.54 / $5,770.26
| Professional | | $2,761.14 | $3,695.54 | $5,770.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,152.95 / $4,826.68
| Professional | | $29.27 | $3,152.95 | $4,826.68 |