- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,025.60 / $6,025.60
| Facility | | $2,570.40 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $1,412.54
| Professional | | $645.65 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $794.33
| Professional | | $691.83 | $691.83 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $11,748.98
| Professional | | $1,380.38 | $1,819.70 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $676.08 / $794.33
| Professional | | $630.96 | $676.08 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,548.82
| Professional | | $691.83 | $812.83 | $1,548.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $3,235.94 / $5,495.41
| Professional | | $870.96 | $3,235.94 | $5,495.41 |