- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.68 / $181.68 / $181.68
| Facility | | $181.68 | $181.68 | $181.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.72 / $69.55 / $107.96
| Professional | | $52.72 | $69.55 | $107.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.21 / $63.87 / $99.00
| Professional | | $43.21 | $63.87 | $99.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.61 / $94.15 / $102.34
| Professional | | $70.61 | $94.15 | $102.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.50 / $80.79 / $97.15
| Professional | | $62.50 | $80.79 | $97.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.68 / $75.56 / $106.69
| Professional | | $56.68 | $75.56 | $106.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.30 / $68.03 / $92.05
| Professional | | $59.30 | $68.03 | $92.05 |