- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.35 / $177.19 / $227.41
| Facility | | $156.35 | $177.19 | $227.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.42 / $227.41 / $227.41
| Professional | | $41.42 | $227.41 | $227.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.22 / $88.47 / $198.44
| Professional | | $72.22 | $88.47 | $198.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.51 / $227.41 / $284.27
| Professional | | $189.51 | $227.41 | $284.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.38 / $227.41 / $284.27
| Professional | | $65.38 | $227.41 | $284.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.74 / $82.32 / $278.58
| Professional | | $51.74 | $82.32 | $278.58 |