- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.38 / $227.10 / $267.18
| Facility | | $200.38 | $227.10 | $267.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.86 / $137.86 / $137.86
| Professional | | $137.86 | $137.86 | $137.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.79 / $202.79 / $410.38
| Professional | | $202.79 | $202.79 | $410.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.19 / $297.57 / $321.35
| Professional | | $42.19 | $297.57 | $321.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.70 / $237.49 / $247.39
| Professional | | $217.70 | $237.49 | $247.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.18 / $297.08 / $354.89
| Professional | | $267.18 | $297.08 | $354.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $317.33 / $550.74
| Professional | | $245.30 | $317.33 | $550.74 |