- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.20 / $306.20 / $306.20
| Facility | | $306.20 | $306.20 | $306.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.65 / $209.52 / $308.19
| Professional | | $31.65 | $209.52 | $308.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.70 / $468.80 / $588.00
| Professional | | $447.70 | $468.80 | $588.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.03 / $32.03 / $304.25
| Professional | | $32.03 | $32.03 | $304.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.05 / $306.20 / $316.50
| Professional | | $201.05 | $306.20 | $316.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.26 / $320.26 / $447.70
| Professional | | $320.26 | $320.26 | $447.70 |