- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.97 / $44.18 / $56.70
| Facility | | $38.97 | $44.18 | $56.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.01 / $35.75 / $39.31
| Professional | | $7.01 | $35.75 | $39.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.70 / $56.70 / $56.70
| Professional | | $56.70 | $56.70 | $56.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.90 / $103.29 / $129.11
| Professional | | $93.90 | $103.29 | $129.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.98 / $56.70 / $66.15
| Professional | | $51.98 | $56.70 | $66.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.25 / $56.70 / $70.88
| Professional | | $47.25 | $56.70 | $70.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.15 / $69.45 / $125.83
| Professional | | $40.15 | $69.45 | $125.83 |