- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,853.42 / $3,853.42 / $3,853.42
| Facility | | $3,853.42 | $3,853.42 | $3,853.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.48 / $2,906.34 / $3,873.00
| Professional | | $2,137.48 | $2,906.34 | $3,873.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,853.43 / $3,853.43 / $3,853.43
| Facility | | $3,853.43 | $3,853.43 | $3,853.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.15 / $3,019.15 / $3,019.15
| Professional | | $3,019.15 | $3,019.15 | $3,019.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.96 / $2,539.59 / $2,962.85
| Professional | | $2,327.96 | $2,539.59 | $2,962.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $3,174.48
| Professional | | $2,116.32 | $2,116.32 | $3,174.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.88 / $2,040.49 / $2,502.17
| Professional | | $1,262.88 | $2,040.49 | $2,502.17 |