- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.40 / $240.72 / $308.94
| Facility | | $212.40 | $240.72 | $308.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.56 / $187.56 / $187.56
| Professional | | $187.56 | $187.56 | $187.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $308.94 / $308.94
| Professional | | $204.17 | $308.94 | $308.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.62 / $524.16 / $610.78
| Professional | | $418.62 | $524.16 | $610.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.20 / $308.94 / $360.43
| Professional | | $283.20 | $308.94 | $360.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.94 / $353.88 / $499.73
| Professional | | $308.94 | $353.88 | $499.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.83 / $347.56 / $579.26
| Professional | | $218.83 | $347.56 | $579.26 |