- 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
- $1,636.73 / $1,800.57 / $1,800.57
| Professional | | $1,636.73 | $1,800.57 | $1,800.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.18 / $2,345.17 / $2,345.17
| Professional | | $1,932.18 | $2,345.17 | $2,345.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,502.37 / $2,811.49 / $3,317.56
| Professional | | $2,502.37 | $2,811.49 | $3,317.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,063.75 / $2,251.37 / $2,626.60
| Professional | | $2,063.75 | $2,251.37 | $2,626.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,912.00 / $2,912.00 / $2,912.00
| Facility | | $2,912.00 | $2,912.00 | $2,912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.66 / $2,345.17 / $3,028.28
| Professional | | $1,913.66 | $2,345.17 | $3,028.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $2,293.44 / $3,205.24
| Professional | | $29.27 | $2,293.44 | $3,205.24 |