- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.91 / $129.09 / $151.88
| Facility | | $113.91 | $129.09 | $151.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.80 / $71.80 / $71.80
| Professional | | $71.80 | $71.80 | $71.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.88 / $155.91 / $207.35
| Professional | | $151.88 | $155.91 | $207.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.77 / $203.62 / $230.25
| Professional | | $31.77 | $203.62 | $230.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.75 / $135.00 / $140.63
| Professional | | $123.75 | $135.00 | $140.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.88 / $181.52 / $183.28
| Professional | | $151.88 | $181.52 | $183.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.41 / $176.71 / $308.12
| Professional | | $139.41 | $176.71 | $308.12 |