- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.50 / $56.10 / $72.00
| Facility | | $49.50 | $56.10 | $72.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $72.00 / $72.00
| Professional | | $13.35 | $72.00 | $72.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.92 / $44.07 / $62.83
| Professional | | $35.92 | $44.07 | $62.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $72.00 / $90.00
| Professional | | $60.00 | $72.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.41 / $72.00 / $90.00
| Professional | | $23.41 | $72.00 | $90.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.75 / $40.97 / $88.20
| Professional | | $25.75 | $40.97 | $88.20 |