- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.73 / $101.55 / $154.97
| Professional | | $88.73 | $101.55 | $154.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,478.00 / $1,478.00 / $1,863.00
| Facility | | $1,478.00 | $1,478.00 | $1,863.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.74 / $141.88 / $427.31
| Professional | | $106.74 | $141.88 | $427.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.87 / $151.36 / $170.38
| Professional | | $131.87 | $151.36 | $170.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.34 / $120.41 / $140.47
| Professional | | $100.34 | $120.41 | $140.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.07 / $108.37 / $165.87
| Professional | | $92.07 | $108.37 | $165.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.45 / $91.63 / $125.05
| Professional | | $75.45 | $91.63 | $125.05 |