- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.94 / $236.80 / $278.58
| Facility | | $208.94 | $236.80 | $278.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.66 / $138.66 / $138.66
| Professional | | $138.66 | $138.66 | $138.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.54 / $211.54 / $300.19
| Professional | | $211.54 | $211.54 | $300.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.89 / $279.44 / $291.91
| Professional | | $54.89 | $279.44 | $291.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.00 / $247.63 / $257.95
| Professional | | $227.00 | $247.63 | $257.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.51 / $278.58 / $355.26
| Professional | | $269.51 | $278.58 | $355.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.95 / $310.49 / $481.47
| Professional | | $230.95 | $310.49 | $481.47 |