- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.66 / $282.95 / $363.14
| Facility | | $249.66 | $282.95 | $363.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.29 / $32.29 / $32.29
| Professional | | $32.29 | $32.29 | $32.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.18 / $363.14 / $363.14
| Professional | | $33.18 | $363.14 | $363.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.56 / $257.23 / $316.88
| Professional | | $89.56 | $257.23 | $316.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.88 / $363.14 / $423.67
| Professional | | $332.88 | $363.14 | $423.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.33 / $363.14 / $453.93
| Professional | | $58.33 | $363.14 | $453.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.16 / $102.08 / $444.85
| Professional | | $64.16 | $102.08 | $444.85 |