- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $412.66 / $412.66 / $412.66
| Facility | | $412.66 | $412.66 | $412.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $215.97 / $293.66
| Professional | | $213.84 | $215.97 | $293.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $213.84 / $213.84
| Professional | | $213.84 | $213.84 | $213.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.44 / $306.44 / $306.44
| Professional | | $306.44 | $306.44 | $306.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.23 / $256.61 / $299.38
| Professional | | $235.23 | $256.61 | $299.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $251.87 / $320.76
| Professional | | $213.84 | $251.87 | $320.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.15 / $253.97 / $270.76
| Professional | | $206.15 | $253.97 | $270.76 |