- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.28 / $81.92 / $96.38
| Facility | | $72.28 | $81.92 | $96.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.49 / $69.31 / $111.99
| Professional | | $48.49 | $69.31 | $111.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.49 / $79.48 / $96.38
| Professional | | $58.49 | $79.48 | $96.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.64 / $101.49 / $112.26
| Professional | | $84.64 | $101.49 | $112.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.53 / $85.67 / $99.95
| Professional | | $73.53 | $85.67 | $99.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.69 / $96.38 / $114.20
| Professional | | $87.69 | $96.38 | $114.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.06 / $104.86 / $173.05
| Professional | | $78.06 | $104.86 | $173.05 |