- 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
- $1,495.19 / $1,631.07 / $2,011.29
| Professional | | $1,495.19 | $1,631.07 | $2,011.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.96 / $2,040.70 / $4,247.76
| Professional | | $1,687.96 | $2,040.70 | $4,247.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,196.81 / $2,468.17 / $2,838.41
| Professional | | $2,196.81 | $2,468.17 | $2,838.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.51 / $1,959.07 / $2,285.58
| Professional | | $1,730.51 | $1,959.07 | $2,285.58 |
- 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
- $1,547.51 / $2,040.70 / $2,814.32
| Professional | | $1,547.51 | $2,040.70 | $2,814.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,586.42 / $2,572.98
| Professional | | $29.27 | $1,586.42 | $2,572.98 |