- 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
- $2,139.16 / $2,139.16 / $2,429.92
| Professional | | $2,139.16 | $2,139.16 | $2,429.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.02 / $2,867.69 / $2,868.82
| Professional | | $2,426.02 | $2,867.69 | $2,868.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,050.20 / $3,426.99 / $4,043.85
| Professional | | $3,050.20 | $3,426.99 | $4,043.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,523.57 / $2,752.98 / $3,211.81
| Professional | | $2,523.57 | $2,752.98 | $3,211.81 |
- 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
- $2,731.50 / $2,867.69 / $3,697.91
| Professional | | $2,731.50 | $2,867.69 | $3,697.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,407.35 / $3,138.85
| Professional | | $29.27 | $2,407.35 | $3,138.85 |