- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $529.53 / $600.13 / $770.22
| Facility | | $529.53 | $600.13 | $770.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $850.00 / $850.00
| Professional | | $850.00 | $850.00 | $850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.22 / $770.22 / $770.22
| Professional | | $770.22 | $770.22 | $770.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.01 / $398.76 / $672.09
| Professional | | $319.01 | $398.76 | $672.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.04 / $770.22 / $898.59
| Professional | | $706.04 | $770.22 | $898.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.83 / $770.22 / $962.78
| Professional | | $287.83 | $770.22 | $962.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.57 / $802.31 / $1,155.33
| Professional | | $545.57 | $802.31 | $1,155.33 |