- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.58 / $350.86 / $450.30
| Facility | | $309.58 | $350.86 | $450.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.42 / $49.42 / $49.42
| Professional | | $49.42 | $49.42 | $49.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.30 / $450.30 / $450.30
| Professional | | $450.30 | $450.30 | $450.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.33 / $129.16 / $392.93
| Professional | | $103.33 | $129.16 | $392.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.78 / $450.30 / $525.35
| Professional | | $412.78 | $450.30 | $525.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.24 / $450.30 / $562.88
| Professional | | $93.24 | $450.30 | $562.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.68 / $469.06 / $675.45
| Professional | | $262.68 | $469.06 | $675.45 |