- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $275.42 / $338.84
| Facility | | $229.09 | $275.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $239.88 / $354.81
| Professional | | $89.13 | $239.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $346.74 / $389.05
| Professional | | $295.12 | $346.74 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $338.84 / $416.87
| Professional | | $309.03 | $338.84 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $281.84 / $416.87
| Professional | | $141.25 | $281.84 | $416.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $331.13 / $501.19
| Professional | | $125.89 | $331.13 | $501.19 |