- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.76 / $1,219.19 / $1,564.74
| Facility | | $1,075.76 | $1,219.19 | $1,564.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.80 / $479.76 / $1,145.00
| Professional | | $427.80 | $479.76 | $1,145.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.74 / $1,564.74 / $1,564.74
| Professional | | $1,564.74 | $1,564.74 | $1,564.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.06 / $975.37 / $1,164.34
| Professional | | $829.06 | $975.37 | $1,164.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.95 / $1,564.74 / $1,955.93
| Professional | | $1,303.95 | $1,564.74 | $1,955.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.48 / $1,018.58 / $1,564.74
| Professional | | $931.48 | $1,018.58 | $1,564.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.19 / $1,222.29 / $1,916.81
| Professional | | $577.19 | $1,222.29 | $1,916.81 |