- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.68 / $214.97 / $252.91
| Facility | | $189.68 | $214.97 | $252.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.44 / $138.44 / $138.44
| Professional | | $138.44 | $138.44 | $138.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.17 / $102.17 / $280.05
| Professional | | $102.17 | $102.17 | $280.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.04 / $188.18 / $296.52
| Professional | | $30.04 | $188.18 | $296.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.07 / $224.81 / $234.18
| Professional | | $206.07 | $224.81 | $234.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.21 / $252.91 / $340.98
| Professional | | $188.21 | $252.91 | $340.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.00 / $275.30 / $510.07
| Professional | | $144.00 | $275.30 | $510.07 |