- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.20 / $49.80 / $49.80
| Professional | | $40.20 | $49.80 | $49.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.07 / $57.90 / $62.13
| Professional | | $50.07 | $57.90 | $62.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.39 / $77.66 / $91.64
| Professional | | $69.39 | $77.66 | $91.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.95 / $55.58 / $64.84
| Professional | | $50.95 | $55.58 | $64.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.25 / $57.90 / $78.59
| Professional | | $47.25 | $57.90 | $78.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.06 / $42.84 / $90.83
| Professional | | $8.06 | $42.84 | $90.83 |