- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.20 / $90.90 / $116.66
| Facility | | $80.20 | $90.90 | $116.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.30 / $83.30 / $83.30
| Professional | | $83.30 | $83.30 | $83.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.66 / $116.66 / $116.66
| Professional | | $116.66 | $116.66 | $116.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.22 / $103.33 / $129.16
| Professional | | $97.22 | $103.33 | $129.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.94 / $116.66 / $136.11
| Professional | | $106.94 | $116.66 | $136.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.22 / $116.66 / $145.83
| Professional | | $97.22 | $116.66 | $145.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.64 / $125.88 / $175.00
| Professional | | $82.64 | $125.88 | $175.00 |