- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.76 / $243.40 / $286.35
| Facility | | $214.76 | $243.40 | $286.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.97 / $142.97 / $142.97
| Professional | | $142.97 | $142.97 | $142.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.58 / $167.58 / $349.20
| Professional | | $167.58 | $167.58 | $349.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.02 / $244.61 / $299.48
| Professional | | $43.02 | $244.61 | $299.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.32 / $254.53 / $265.14
| Professional | | $233.32 | $254.53 | $265.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.80 / $286.35 / $367.83
| Professional | | $249.80 | $286.35 | $367.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.61 / $319.37 / $573.85
| Professional | | $231.61 | $319.37 | $573.85 |