- 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
- $340.18 / $340.18 / $340.18
| Professional | | $340.18 | $340.18 | $340.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.02 / $770.22 / $770.22
| Professional | | $361.02 | $770.22 | $770.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.48 / $571.28 / $672.09
| Professional | | $360.48 | $571.28 | $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
- $641.85 / $770.22 / $962.78
| Professional | | $641.85 | $770.22 | $962.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.57 / $866.50 / $1,444.16
| Professional | | $545.57 | $866.50 | $1,444.16 |