- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $576.26 / $576.26 / $576.26
| Facility | | $576.26 | $576.26 | $576.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.79 / $672.30 / $925.78
| Professional | | $516.79 | $672.30 | $925.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.33 / $880.97 / $1,109.78
| Professional | | $841.33 | $880.97 | $1,109.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.13 / $757.46 / $1,178.27
| Professional | | $589.13 | $757.46 | $1,178.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.01 / $576.26 / $925.78
| Professional | | $393.01 | $576.26 | $925.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.14 / $702.94 / $739.85
| Professional | | $700.14 | $702.94 | $739.85 |