- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.68 / $466.57 / $598.79
| Facility | | $411.68 | $466.57 | $598.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.51 / $1,104.51 / $1,104.51
| Professional | | $1,104.51 | $1,104.51 | $1,104.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.79 / $598.79 / $598.79
| Professional | | $598.79 | $598.79 | $598.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.46 / $1,709.91 / $2,137.39
| Professional | | $1,554.46 | $1,709.91 | $2,137.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.90 / $598.79 / $698.60
| Professional | | $548.90 | $598.79 | $698.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.00 / $598.79 / $748.50
| Professional | | $499.00 | $598.79 | $748.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.15 / $733.53 / $2,082.98
| Professional | | $424.15 | $733.53 | $2,082.98 |