- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $263.03 / $316.23
| Facility | | $218.78 | $263.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $229.09 / $331.13
| Professional | | $131.83 | $229.09 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $141.25 / $316.23
| Professional | | $125.89 | $141.25 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $389.05 / $436.52
| Professional | | $302.00 | $389.05 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $316.23 / $398.11
| Professional | | $288.40 | $316.23 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $316.23 / $398.11
| Professional | | $147.91 | $316.23 | $398.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $331.13 / $467.74
| Professional | | $251.19 | $331.13 | $467.74 |