- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $741.31 / $1,047.13
| Professional | | $645.65 | $741.31 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $851.14 / $1,047.13
| Professional | | $741.31 | $851.14 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,348.96
| Professional | | $1,000.00 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $891.25 / $1,096.48
| Professional | | $776.25 | $891.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $870.96 / $1,148.15
| Professional | | $537.03 | $870.96 | $1,148.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,691.53 / $6,165.95
| Professional | | $891.25 | $2,691.53 | $6,165.95 |