- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.65 / $709.07 / $910.03
| Facility | | $625.65 | $709.07 | $910.03 |
- 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
- $910.03 / $910.03 / $910.03
| Professional | | $910.03 | $910.03 | $910.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.29 / $690.86 / $794.09
| Professional | | $604.29 | $690.86 | $794.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.20 / $910.03 / $1,061.70
| Professional | | $834.20 | $910.03 | $1,061.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.36 / $910.03 / $1,137.54
| Professional | | $758.36 | $910.03 | $1,137.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.15 / $894.86 / $1,365.05
| Professional | | $627.15 | $894.86 | $1,365.05 |