- 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
- $2,512.64 / $2,512.64 / $2,867.13
| Professional | | $2,512.64 | $2,512.64 | $2,867.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,865.95 / $3,368.36 / $3,382.63
| Professional | | $2,865.95 | $3,368.36 | $3,382.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,680.42 / $4,135.07 / $4,879.38
| Professional | | $3,680.42 | $4,135.07 | $4,879.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,964.16 / $3,233.63 / $3,772.57
| Professional | | $2,964.16 | $3,233.63 | $3,772.57 |
- 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
- $2,748.58 / $3,368.36 / $4,364.72
| Professional | | $2,748.58 | $3,368.36 | $4,364.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,836.19 / $3,693.26
| Professional | | $29.27 | $2,836.19 | $3,693.26 |