- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $558.11 / $632.53 / $811.80
| Facility | | $558.11 | $632.53 | $811.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.50 / $668.50 / $668.50
| Professional | | $668.50 | $668.50 | $668.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.80 / $811.80 / $811.80
| Professional | | $811.80 | $811.80 | $811.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.19 / $865.91 / $1,082.39
| Professional | | $787.19 | $865.91 | $1,082.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.15 / $811.80 / $947.10
| Professional | | $744.15 | $811.80 | $947.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.29 / $811.80 / $1,111.67
| Professional | | $781.29 | $811.80 | $1,111.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.03 / $861.06 / $1,522.13
| Professional | | $575.03 | $861.06 | $1,522.13 |