- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.34 / $749.51 / $961.94
| Facility | | $661.34 | $749.51 | $961.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.56 / $961.94 / $961.94
| Professional | | $193.56 | $961.94 | $961.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.89 / $801.62 / $866.31
| Professional | | $706.89 | $801.62 | $866.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.62 / $961.94 / $1,202.43
| Professional | | $801.62 | $961.94 | $1,202.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.68 / $961.94 / $1,202.43
| Professional | | $336.68 | $961.94 | $1,202.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.55 / $722.99 / $1,178.38
| Professional | | $506.55 | $722.99 | $1,178.38 |