- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $627.58 / $627.58 / $627.58
| Facility | | $627.58 | $627.58 | $627.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $349.56
| Professional | | $346.11 | $346.11 | $349.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Professional | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.78 / $494.78 / $494.78
| Professional | | $494.78 | $494.78 | $494.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.72 / $415.33 / $484.55
| Professional | | $380.72 | $415.33 | $484.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $406.67 / $519.16
| Professional | | $346.11 | $406.67 | $519.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.48 / $393.54 / $437.17
| Professional | | $313.48 | $393.54 | $437.17 |