- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.45 / $88.91 / $104.60
| Facility | | $78.45 | $88.91 | $104.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.87 / $48.87 / $48.87
| Professional | | $48.87 | $48.87 | $48.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.58 / $82.58 / $147.33
| Professional | | $82.58 | $82.58 | $147.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.42 / $114.30 / $126.44
| Professional | | $17.42 | $114.30 | $126.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.23 / $92.98 / $96.85
| Professional | | $85.23 | $92.98 | $96.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.60 / $112.34 / $123.55
| Professional | | $104.60 | $112.34 | $123.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.89 / $117.40 / $207.07
| Professional | | $94.89 | $117.40 | $207.07 |