- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,513.56
| Professional | | $758.58 | $1,047.13 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $3,090.30
| Professional | | $2,187.76 | $2,818.38 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $1,548.82
| Professional | | $1,148.15 | $1,348.96 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,089.30 / $2,187.76
| Professional | | $1,258.93 | $2,089.30 | $2,187.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $3,630.78
| Professional | | $1,412.54 | $2,041.74 | $3,630.78 |