- 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
- $1,996.76 / $2,201.55 / $2,764.45
| Professional | | $1,996.76 | $2,201.55 | $2,764.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,129.98 / $2,740.04 / $5,745.60
| Professional | | $2,129.98 | $2,740.04 | $5,745.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,955.88 / $3,321.02 / $3,819.17
| Professional | | $2,955.88 | $3,321.02 | $3,819.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.55 / $2,630.44 / $3,068.84
| Professional | | $2,323.55 | $2,630.44 | $3,068.84 |
- 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
- $2,193.42 / $2,802.70 / $4,056.81
| Professional | | $2,193.42 | $2,802.70 | $4,056.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,019.94 / $3,135.26
| Professional | | $29.27 | $2,019.94 | $3,135.26 |