- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $295.12 / $346.74
| Facility | | $263.03 | $295.12 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $204.17 / $354.81
| Professional | | $169.82 | $204.17 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $346.74 / $562.34
| Professional | | $169.82 | $346.74 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $407.38 / $407.38
| Professional | | $354.81 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $309.03 / $363.08
| Professional | | $281.84 | $309.03 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $281.84 / $446.68
| Professional | | $194.98 | $281.84 | $446.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $380.19 / $602.56
| Professional | | $239.88 | $380.19 | $602.56 |