- 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
- $2,820.13 / $2,820.13 / $3,211.01
| Professional | | $2,820.13 | $2,820.13 | $3,211.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,208.44 / $3,782.34 / $3,792.00
| Professional | | $3,208.44 | $3,782.34 | $3,792.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.03 / $4,536.84 / $5,353.47
| Professional | | $4,038.03 | $4,536.84 | $5,353.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,328.46 / $3,631.04 / $4,236.22
| Professional | | $3,328.46 | $3,631.04 | $4,236.22 |
- 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
- $3,086.39 / $3,782.34 / $4,896.47
| Professional | | $3,086.39 | $3,782.34 | $4,896.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $3,129.56 / $4,145.06
| Professional | | $29.27 | $3,129.56 | $4,145.06 |