- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.88 / $743.33 / $954.00
| Facility | | $655.88 | $743.33 | $954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.00 / $759.00 / $759.00
| Professional | | $759.00 | $759.00 | $759.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.00 / $954.00 / $954.00
| Professional | | $954.00 | $954.00 | $954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.59 / $832.46 / $993.75
| Professional | | $707.59 | $832.46 | $993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.00 / $954.00 / $1,192.50
| Professional | | $795.00 | $954.00 | $1,192.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.00 / $954.00 / $1,192.50
| Professional | | $795.00 | $954.00 | $1,192.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.50 / $993.75 / $1,431.00
| Professional | | $556.50 | $993.75 | $1,431.00 |