- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.15 / $266.50 / $342.04
| Facility | | $235.15 | $266.50 | $342.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.70 / $342.04 / $342.04
| Professional | | $68.70 | $342.04 | $342.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.90 / $253.82 / $298.45
| Professional | | $216.90 | $253.82 | $298.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.02 / $342.04 / $427.55
| Professional | | $285.02 | $342.04 | $427.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.71 / $342.04 / $427.55
| Professional | | $119.71 | $342.04 | $427.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.72 / $233.15 / $418.99
| Professional | | $153.72 | $233.15 | $418.99 |