- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.80 / $30.40 / $67.15
| Facility | | $28.80 | $30.40 | $67.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $174.32 / $474.00
| Professional | | $24.00 | $174.32 | $474.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.24 / $140.24 / $140.24
| Facility | | $140.24 | $140.24 | $140.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.41 / $179.00 / $242.53
| Professional | | $159.41 | $179.00 | $242.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.72 / $172.72 / $247.97
| Professional | | $77.72 | $172.72 | $247.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.63 / $216.76 / $226.43
| Professional | | $73.63 | $216.76 | $226.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.78 / $45.68 / $50.72
| Professional | | $26.78 | $45.68 | $50.72 |