- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.76 / $643.76 / $643.76
| Facility | | $643.76 | $643.76 | $643.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.18 / $373.70 / $493.27
| Professional | | $359.18 | $373.70 | $493.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.19 / $359.19 / $359.19
| Professional | | $359.19 | $359.19 | $359.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.58 / $367.58 / $367.58
| Professional | | $367.58 | $367.58 | $367.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.11 / $431.03 / $502.87
| Professional | | $395.11 | $431.03 | $502.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.19 / $416.52 / $538.79
| Professional | | $359.19 | $416.52 | $538.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.88 / $402.35 / $447.76
| Professional | | $321.88 | $402.35 | $447.76 |