- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.59 / $83.40 / $98.12
| Facility | | $73.59 | $83.40 | $98.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.50 / $51.50 / $51.50
| Professional | | $51.50 | $51.50 | $51.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.59 / $78.59 / $107.47
| Professional | | $78.59 | $78.59 | $107.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.71 / $117.98 / $120.79
| Professional | | $27.71 | $117.98 | $120.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.95 / $87.22 / $90.85
| Professional | | $79.95 | $87.22 | $90.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.43 / $98.12 / $132.99
| Professional | | $58.43 | $98.12 | $132.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.38 / $112.32 / $206.31
| Professional | | $87.38 | $112.32 | $206.31 |