- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $3,890.45
| Facility | | $1,513.56 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $338.84 / $562.34
| Professional | | $281.84 | $338.84 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $380.19 / $501.19
| Professional | | $354.81 | $380.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $537.03 / $2,630.27
| Professional | | $85.11 | $537.03 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $467.74 / $588.84
| Professional | | $371.54 | $467.74 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $389.05 / $501.19
| Professional | | $263.03 | $389.05 | $501.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $436.52 / $3,090.30
| Professional | | $218.78 | $436.52 | $3,090.30 |