- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.71 / $164.00 / $210.48
| Facility | | $144.71 | $164.00 | $210.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.96 / $92.96 / $92.96
| Professional | | $92.96 | $92.96 | $92.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.75 / $210.48 / $210.48
| Professional | | $98.75 | $210.48 | $210.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.20 / $204.08 / $248.33
| Professional | | $170.20 | $204.08 | $248.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.94 / $210.48 / $245.56
| Professional | | $192.94 | $210.48 | $245.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.40 / $210.48 / $263.10
| Professional | | $175.40 | $210.48 | $263.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.09 / $236.79 / $394.65
| Professional | | $149.09 | $236.79 | $394.65 |