- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $575.44 / $691.83
| Facility | | $478.63 | $575.44 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $549.54 / $562.34
| Professional | | $426.58 | $549.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $691.83
| Professional | | $426.58 | $426.58 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,412.54
| Professional | | $1,000.00 | $1,288.25 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $870.96
| Professional | | $575.44 | $691.83 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $812.83 / $1,122.02
| Professional | | $245.47 | $812.83 | $1,122.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,047.13 / $1,445.44
| Professional | | $645.65 | $1,047.13 | $1,445.44 |