- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.85 / $308.08 / $395.41
| Facility | | $271.85 | $308.08 | $395.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.64 / $174.64 / $174.64
| Professional | | $174.64 | $174.64 | $174.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.32 / $395.41 / $395.41
| Professional | | $185.32 | $395.41 | $395.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.54 / $372.35 / $411.89
| Professional | | $310.54 | $372.35 | $411.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.46 / $395.41 / $461.31
| Professional | | $362.46 | $395.41 | $461.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.51 / $395.41 / $494.27
| Professional | | $329.51 | $395.41 | $494.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.08 / $444.84 / $741.40
| Professional | | $280.08 | $444.84 | $741.40 |