- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $154.88 / $181.97
| Facility | | $134.90 | $154.88 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $112.20 / $177.83
| Professional | | $85.11 | $112.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $257.04 / $323.59
| Professional | | $181.97 | $257.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $478.63 / $537.03
| Professional | | $407.38 | $478.63 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $169.82 / $194.98
| Professional | | $154.88 | $169.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $213.80 / $316.23
| Professional | | $125.89 | $213.80 | $316.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $501.19
| Professional | | $169.82 | $208.93 | $501.19 |