- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.82 / $76.09 / $137.47
| Professional | | $39.82 | $76.09 | $137.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.25 / $118.24 / $141.88
| Professional | | $88.25 | $118.24 | $141.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.16 / $78.25 / $135.16
| Professional | | $67.16 | $78.25 | $135.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.63 / $100.27 / $118.24
| Professional | | $47.63 | $100.27 | $118.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.42 / $115.56 / $138.80
| Professional | | $84.42 | $115.56 | $138.80 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $56.86 / $118.57
| Professional | | $29.27 | $56.86 | $118.57 |