- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.22 / $709.71 / $910.86
| Facility | | $626.22 | $709.71 | $910.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.23 / $425.23 / $425.23
| Professional | | $425.23 | $425.23 | $425.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.96 / $910.86 / $910.86
| Professional | | $438.96 | $910.86 | $910.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.12 / $840.14 / $1,002.91
| Professional | | $714.12 | $840.14 | $1,002.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.05 / $910.86 / $1,138.58
| Professional | | $759.05 | $910.86 | $1,138.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.33 / $910.86 / $1,138.58
| Professional | | $802.33 | $910.86 | $1,138.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.19 / $1,115.80 / $1,707.86
| Professional | | $645.19 | $1,115.80 | $1,707.86 |