- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $5,495.41
| Facility | | $1,949.84 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $758.58
| Professional | | $524.81 | $616.60 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $645.65 / $660.69
| Professional | | $524.81 | $645.65 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $2,691.53
| Professional | | $794.33 | $1,023.29 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $588.84 / $741.31
| Professional | | $549.54 | $588.84 | $741.31 |
- 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
- $549.54 / $676.08 / $851.14
| Professional | | $549.54 | $676.08 | $851.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $4,073.80 / $7,943.28
| Professional | | $630.96 | $4,073.80 | $7,943.28 |