- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.07 / $1,162.07 / $1,162.07
| Facility | | $1,162.07 | $1,162.07 | $1,162.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $1,021.04 / $1,042.44
| Professional | | $119.94 | $1,021.04 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.65 / $2,407.65 / $2,521.10
| Professional | | $2,407.65 | $2,407.65 | $2,521.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.19 / $131.19 / $131.19
| Professional | | $131.19 | $131.19 | $131.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.34 / $1,162.07 / $1,190.24
| Professional | | $632.34 | $1,162.07 | $1,190.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.69 / $1,626.69 / $1,626.69
| Professional | | $1,626.69 | $1,626.69 | $1,626.69 |