- 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
- $1,552.60 / $1,552.60 / $2,378.12
| Professional | | $1,552.60 | $1,552.60 | $2,378.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.75 / $1,925.65 / $2,310.78
| Professional | | $1,502.75 | $1,925.65 | $2,310.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.36 / $2,231.85 / $2,634.97
| Professional | | $2,039.36 | $2,231.85 | $2,634.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.57 / $1,848.62 / $2,156.73
| Professional | | $1,694.57 | $1,848.62 | $2,156.73 |
- 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
- $1,558.29 / $1,925.65 / $2,457.35
| Professional | | $1,558.29 | $1,925.65 | $2,457.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,506.18 / $2,098.62
| Professional | | $29.27 | $1,506.18 | $2,098.62 |