- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $147.91 / $181.97
| Facility | | $123.03 | $147.91 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $128.82 / $190.55
| Professional | | $100.00 | $128.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $181.97
| Professional | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $186.21 / $204.17
| Professional | | $151.36 | $186.21 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $181.97 / $223.87
| Professional | | $165.96 | $181.97 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $151.36 / $223.87
| Professional | | $75.86 | $151.36 | $223.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $177.83 / $269.15
| Professional | | $109.65 | $177.83 | $269.15 |