- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $181.97 / $223.87
| Facility | | $151.36 | $181.97 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $158.49 / $234.42
| Professional | | $100.00 | $158.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $100.00 / $223.87
| Professional | | $95.50 | $100.00 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $239.88 / $263.03
| Professional | | $186.21 | $239.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $223.87 / $275.42
| Professional | | $204.17 | $223.87 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $186.21 / $275.42
| Professional | | $93.33 | $186.21 | $275.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $269.15 / $416.87
| Professional | | $158.49 | $269.15 | $416.87 |