- 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
- $2,024.50 / $2,200.03 / $2,718.41
| Professional | | $2,024.50 | $2,200.03 | $2,718.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,278.53 / $2,737.24 / $5,738.22
| Professional | | $2,278.53 | $2,737.24 | $5,738.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,955.50 / $3,320.59 / $3,818.68
| Professional | | $2,955.50 | $3,320.59 | $3,818.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,321.17 / $2,627.75 / $3,065.71
| Professional | | $2,321.17 | $2,627.75 | $3,065.71 |
- 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
- $2,189.84 / $2,798.13 / $3,786.49
| Professional | | $2,189.84 | $2,798.13 | $3,786.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,075.89 / $3,427.46
| Professional | | $29.27 | $2,075.89 | $3,427.46 |