- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.52 / $126.39 / $148.69
| Facility | | $111.52 | $126.39 | $148.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.84 / $100.15 / $357.10
| Professional | | $72.84 | $100.15 | $357.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.20 / $104.08 / $148.69
| Professional | | $80.20 | $104.08 | $148.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.08 / $155.97 / $172.54
| Professional | | $130.08 | $155.97 | $172.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.44 / $132.16 / $154.19
| Professional | | $113.44 | $132.16 | $154.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.74 / $148.69 / $169.98
| Professional | | $118.74 | $148.69 | $169.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.49 / $160.51 / $249.62
| Professional | | $103.49 | $160.51 | $249.62 |