- 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
- $2,128.25 / $2,128.25 / $2,509.44
| Professional | | $2,128.25 | $2,128.25 | $2,509.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,463.03 / $3,113.53 / $3,113.53
| Professional | | $2,463.03 | $3,113.53 | $3,113.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,389.44 / $3,808.14 / $4,493.60
| Professional | | $3,389.44 | $3,808.14 | $4,493.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,739.90 / $2,988.98 / $3,487.15
| Professional | | $2,739.90 | $2,988.98 | $3,487.15 |
- 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
- $2,540.64 / $3,113.53 / $3,930.96
| Professional | | $2,540.64 | $3,113.53 | $3,930.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,316.21 / $3,460.71
| Professional | | $29.27 | $2,316.21 | $3,460.71 |