- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.41 / $349.41 / $349.41
| Facility | | $349.41 | $349.41 | $349.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.07 / $172.77 / $351.38
| Professional | | $36.07 | $172.77 | $351.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.40 / $534.45 / $670.35
| Professional | | $510.40 | $534.45 | $670.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.86 / $32.86 / $346.88
| Professional | | $32.86 | $32.86 | $346.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.20 / $349.41 / $358.01
| Professional | | $190.20 | $349.41 | $358.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.14 / $365.14 / $510.40
| Professional | | $365.14 | $365.14 | $510.40 |