- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $831.76 / $1,023.29
| Facility | | $691.83 | $831.76 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $1,202.26
| Professional | | $676.08 | $851.14 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,023.29
| Professional | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $891.25 / $1,047.13
| Professional | | $851.14 | $891.25 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,023.29 / $1,258.93
| Professional | | $933.25 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $851.14 / $1,258.93
| Professional | | $426.58 | $851.14 | $1,258.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,148.15 / $1,513.56
| Professional | | $724.44 | $1,148.15 | $1,513.56 |