- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.99 / $223.26 / $262.66
| Facility | | $196.99 | $223.26 | $262.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.59 / $265.99 / $629.66
| Professional | | $165.59 | $265.99 | $629.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.77 / $183.39 / $262.66
| Professional | | $145.77 | $183.39 | $262.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.82 / $276.77 / $306.16
| Professional | | $230.82 | $276.77 | $306.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.40 / $233.47 / $272.38
| Professional | | $200.40 | $233.47 | $272.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.10 / $262.66 / $304.95
| Professional | | $229.10 | $262.66 | $304.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.48 / $285.36 / $452.82
| Professional | | $181.48 | $285.36 | $452.82 |