- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.70 / $325.70 / $325.70
| Facility | | $325.70 | $325.70 | $325.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.27 / $282.27 / $293.68
| Professional | | $282.27 | $282.27 | $293.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.70 / $325.70 / $325.70
| Facility | | $325.70 | $325.70 | $325.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $289.08 / $289.08
| Professional | | $289.08 | $289.08 | $289.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.58 / $227.58 / $227.58
| Professional | | $227.58 | $227.58 | $227.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.06 / $283.42 / $425.13
| Professional | | $187.06 | $283.42 | $425.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $188.61 / $228.43
| Professional | | $155.00 | $188.61 | $228.43 |