- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.27 / $127.23 / $149.69
| Facility | | $112.27 | $127.23 | $149.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.44 / $70.44 / $70.44
| Professional | | $70.44 | $70.44 | $70.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.69 / $154.97 / $167.60
| Professional | | $149.69 | $154.97 | $167.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.39 / $219.42 / $256.93
| Professional | | $28.39 | $219.42 | $256.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.97 / $133.06 / $138.60
| Professional | | $121.97 | $133.06 | $138.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.69 / $178.17 / $189.68
| Professional | | $149.69 | $178.17 | $189.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.05 / $188.43 / $303.64
| Professional | | $129.05 | $188.43 | $303.64 |