- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $91.20 / $141.25
| Professional | | $67.61 | $91.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $77.62 / $128.82
| Professional | | $63.10 | $77.62 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $151.36 / $190.55
| Professional | | $112.20 | $151.36 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $114.82 / $151.36
| Professional | | $89.13 | $114.82 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $100.00 / $134.90
| Professional | | $74.13 | $100.00 | $134.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $77.62 / $151.36
| Professional | | $44.67 | $77.62 | $151.36 |