- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $48.98 / $61.66
| Professional | | $39.81 | $48.98 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $57.54 / $61.66
| Professional | | $50.12 | $57.54 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $81.28 / $91.20
| Professional | | $72.44 | $81.28 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $50.12 / $61.66
| Professional | | $45.71 | $50.12 | $61.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $63.10 / $79.43
| Professional | | $46.77 | $63.10 | $79.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $42.66 / $91.20
| Professional | | $8.13 | $42.66 | $91.20 |