- 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
- $3,280.23 / $3,463.17 / $4,576.74
| Professional | | $3,280.23 | $3,463.17 | $4,576.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,453.86 / $4,654.74 / $9,658.94
| Professional | | $3,453.86 | $4,654.74 | $9,658.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,008.45 / $5,627.14 / $6,471.21
| Professional | | $5,008.45 | $5,627.14 | $6,471.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,947.22 / $4,468.55 / $5,213.31
| Professional | | $3,947.22 | $4,468.55 | $5,213.31 |
- 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
- $3,693.38 / $4,719.31 / $6,401.98
| Professional | | $3,693.38 | $4,719.31 | $6,401.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,486.45 / $5,154.02
| Professional | | $29.27 | $3,486.45 | $5,154.02 |