- 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
- $1,835.55 / $1,927.94 / $3,538.19
| Professional | | $1,835.55 | $1,927.94 | $3,538.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.51 / $2,873.59 / $2,873.59
| Professional | | $2,412.51 | $2,873.59 | $2,873.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,150.62 / $3,539.81 / $4,176.97
| Professional | | $3,150.62 | $3,539.81 | $4,176.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,528.76 / $2,758.64 / $3,218.42
| Professional | | $2,528.76 | $2,758.64 | $3,218.42 |
- 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
- $2,344.85 / $2,873.59 / $3,688.29
| Professional | | $2,344.85 | $2,873.59 | $3,688.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,221.10 / $3,138.98
| Professional | | $29.27 | $2,221.10 | $3,138.98 |