- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.59 / $47.13 / $60.49
| Facility | | $41.59 | $47.13 | $60.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.85 / $58.85 / $58.85
| Professional | | $58.85 | $58.85 | $58.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.83 / $60.49 / $60.49
| Professional | | $40.83 | $60.49 | $60.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.95 / $108.08 / $126.47
| Professional | | $81.95 | $108.08 | $126.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.41 / $60.49 / $75.62
| Professional | | $50.41 | $60.49 | $75.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.17 / $60.49 / $97.85
| Professional | | $21.17 | $60.49 | $97.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.46 / $91.53 / $126.74
| Professional | | $56.46 | $91.53 | $126.74 |