- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.50 / $729.30 / $936.00
| Facility | | $643.50 | $729.30 | $936.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.93 / $955.93 / $955.93
| Professional | | $955.93 | $955.93 | $955.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.00 / $936.00 / $936.00
| Professional | | $936.00 | $936.00 | $936.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.00 / $824.91 / $1,031.14
| Professional | | $780.00 | $824.91 | $1,031.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.00 / $936.00 / $1,092.00
| Professional | | $858.00 | $936.00 | $1,092.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.00 / $936.00 / $1,170.00
| Professional | | $780.00 | $936.00 | $1,170.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.00 / $1,004.89 / $1,404.00
| Professional | | $663.00 | $1,004.89 | $1,404.00 |