- 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
- $257.04 / $524.81 / $3,715.35
| Professional | | $257.04 | $524.81 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $724.44 / $5,754.40
| Professional | | $323.59 | $724.44 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $660.69 / $3,311.31
| Professional | | $562.34 | $660.69 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $3,019.95 / $3,890.45
| Professional | | $263.03 | $3,019.95 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $676.08 / $3,801.89
| Professional | | $281.84 | $676.08 | $3,801.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,041.74 / $3,890.45
| Professional | | $331.13 | $2,041.74 | $3,890.45 |