- 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
- $794.33 / $831.76 / $1,000.00
| Professional | | $794.33 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $954.99
| Professional | | $776.25 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $14,791.08
| Professional | | $1,122.02 | $1,479.11 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $831.76 / $1,047.13
| Professional | | $776.25 | $831.76 | $1,047.13 |
- 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
- $776.25 / $954.99 / $1,230.27
| Professional | | $776.25 | $954.99 | $1,230.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $776.25 / $1,230.27
| Professional | | $29.51 | $776.25 | $1,230.27 |