- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $740.03 / $838.70 / $1,076.40
| Facility | | $740.03 | $838.70 | $1,076.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.77 / $650.00 / $1,231.84
| Professional | | $457.77 | $650.00 | $1,231.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.40 / $1,076.40 / $1,076.40
| Professional | | $1,076.40 | $1,076.40 | $1,076.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.38 / $939.27 / $1,121.25
| Professional | | $798.38 | $939.27 | $1,121.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.00 / $1,076.40 / $1,345.50
| Professional | | $897.00 | $1,076.40 | $1,345.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.00 / $1,076.40 / $1,345.50
| Professional | | $897.00 | $1,076.40 | $1,345.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.45 / $1,318.59 / $2,018.25
| Professional | | $762.45 | $1,318.59 | $2,018.25 |