- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.73 / $256.97 / $329.80
| Facility | | $226.73 | $256.97 | $329.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.66 / $145.66 / $145.66
| Professional | | $145.66 | $145.66 | $145.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.79 / $329.80 / $329.80
| Professional | | $149.79 | $329.80 | $329.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.83 / $324.30 / $377.89
| Professional | | $274.83 | $324.30 | $377.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.31 / $329.80 / $384.76
| Professional | | $302.31 | $329.80 | $384.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.83 / $329.80 / $412.25
| Professional | | $274.83 | $329.80 | $412.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.61 / $371.02 / $618.37
| Professional | | $233.61 | $371.02 | $618.37 |