- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $758.58 / $1,023.29
| Professional | | $676.08 | $758.58 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $1,023.29
| Professional | | $724.44 | $851.14 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,071.52 / $1,288.25
| Professional | | $977.24 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $831.76 / $1,047.13
| Professional | | $741.31 | $831.76 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $831.76 / $1,174.90
| Professional | | $575.44 | $831.76 | $1,174.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $794.33 / $1,174.90
| Professional | | $29.51 | $794.33 | $1,174.90 |