- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.16 / $125.98 / $148.22
| Facility | | $111.16 | $125.98 | $148.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.73 / $100.89 / $171.86
| Professional | | $73.73 | $100.89 | $171.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.98 / $119.82 / $148.22
| Professional | | $87.98 | $119.82 | $148.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.47 / $152.84 / $169.08
| Professional | | $127.47 | $152.84 | $169.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.08 / $131.75 / $153.71
| Professional | | $113.08 | $131.75 | $153.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.53 / $148.22 / $172.91
| Professional | | $132.53 | $148.22 | $172.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.66 / $161.01 / $260.18
| Professional | | $116.66 | $161.01 | $260.18 |