- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.71 / $494.71 / $494.71
| Professional | | $494.71 | $494.71 | $494.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.42 / $1,154.42 / $1,154.42
| Facility | | $1,154.42 | $1,154.42 | $1,154.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.10 / $831.10 / $1,598.50
| Professional | | $831.10 | $831.10 | $1,598.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.18 / $1,521.65 / $1,521.65
| Professional | | $1,453.18 | $1,521.65 | $1,521.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.91 / $1,453.18 / $2,034.45
| Professional | | $871.91 | $1,453.18 | $2,034.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.33 / $1,154.42 / $1,598.50
| Professional | | $779.33 | $1,154.42 | $1,598.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.58 / $1,210.71 / $1,383.16
| Professional | | $1,170.58 | $1,210.71 | $1,383.16 |