- 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
- $2,334.84 / $2,551.48 / $3,956.01
| Professional | | $2,334.84 | $2,551.48 | $3,956.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,528.80 / $3,220.43 / $6,680.13
| Professional | | $2,528.80 | $3,220.43 | $6,680.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,457.49 / $3,884.59 / $4,467.28
| Professional | | $3,457.49 | $3,884.59 | $4,467.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,730.92 / $3,091.61 / $3,606.88
| Professional | | $2,730.92 | $3,091.61 | $3,606.88 |
- 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
- $2,528.92 / $3,220.43 / $4,522.91
| Professional | | $2,528.92 | $3,220.43 | $4,522.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,469.78 / $3,945.65
| Professional | | $29.27 | $2,469.78 | $3,945.65 |