- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.38 / $150.38 / $150.38
| Facility | | $150.38 | $150.38 | $150.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $97.68 / $152.38
| Professional | | $14.40 | $97.68 | $152.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.38 / $150.38 / $150.38
| Facility | | $150.38 | $150.38 | $150.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.00 / $133.56 / $237.23
| Professional | | $18.00 | $133.56 | $237.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.16 / $130.60 / $165.39
| Professional | | $112.16 | $130.60 | $165.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.39 / $150.38 / $270.74
| Professional | | $107.39 | $150.38 | $270.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $250.00 / $257.50
| Professional | | $120.00 | $250.00 | $257.50 |