- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.08 / $302.70 / $388.50
| Facility | | $267.08 | $302.70 | $388.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.71 / $388.50 / $388.50
| Professional | | $100.71 | $388.50 | $388.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.08 / $300.99 / $339.01
| Professional | | $272.08 | $300.99 | $339.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.75 / $388.50 / $485.63
| Professional | | $323.75 | $388.50 | $485.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.97 / $388.50 / $485.63
| Professional | | $135.97 | $388.50 | $485.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.63 / $382.03 / $582.75
| Professional | | $226.63 | $382.03 | $582.75 |