- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.03 / $128.10 / $164.40
| Facility | | $113.03 | $128.10 | $164.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.61 / $72.61 / $72.61
| Professional | | $72.61 | $72.61 | $72.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.59 / $164.40 / $164.40
| Professional | | $74.59 | $164.40 | $164.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.00 / $161.66 / $188.38
| Professional | | $137.00 | $161.66 | $188.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.69 / $164.40 / $191.80
| Professional | | $150.69 | $164.40 | $191.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.00 / $205.50 / $205.50
| Professional | | $137.00 | $205.50 | $205.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.45 / $184.95 / $308.25
| Professional | | $116.45 | $184.95 | $308.25 |