- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.20 / $570.20 / $570.20
| Facility | | $570.20 | $570.20 | $570.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $350.38
| Professional | | $318.52 | $318.52 | $350.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $373.63
| Professional | | $318.52 | $318.52 | $373.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.49 / $387.64 / $445.79
| Professional | | $329.49 | $387.64 | $445.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $382.24 / $477.80
| Professional | | $318.52 | $382.24 | $477.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.58 / $335.30 / $477.80
| Professional | | $317.58 | $335.30 | $477.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.30 / $363.91 / $401.65
| Professional | | $290.30 | $363.91 | $401.65 |