- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.89 / $234.48 / $300.94
| Facility | | $206.89 | $234.48 | $300.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.94 / $300.94 / $300.94
| Professional | | $300.94 | $300.94 | $300.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.27 / $470.35 / $520.29
| Professional | | $392.27 | $470.35 | $520.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.78 / $300.94 / $376.17
| Professional | | $250.78 | $300.94 | $376.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $300.94 / $476.95
| Professional | | $105.33 | $300.94 | $476.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.16 / $368.65 / $820.02
| Professional | | $213.16 | $368.65 | $820.02 |