- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.03 / $193.83 / $248.77
| Facility | | $171.03 | $193.83 | $248.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.87 / $109.87 / $109.87
| Professional | | $109.87 | $109.87 | $109.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.61 / $248.77 / $248.77
| Professional | | $116.61 | $248.77 | $248.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.97 / $336.26 / $391.84
| Professional | | $284.97 | $336.26 | $391.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.04 / $248.77 / $290.23
| Professional | | $228.04 | $248.77 | $290.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.31 / $248.77 / $310.97
| Professional | | $207.31 | $248.77 | $310.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.21 / $279.87 / $466.45
| Professional | | $176.21 | $279.87 | $466.45 |