- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $72.44 / $87.10
| Facility | | $60.26 | $72.44 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $67.61 / $95.50
| Professional | | $44.67 | $67.61 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $87.10
| Professional | | $43.65 | $43.65 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $100.00 / $120.23
| Professional | | $87.10 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $87.10 / $109.65
| Professional | | $81.28 | $87.10 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $83.18 / $117.49
| Professional | | $41.69 | $83.18 | $117.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $107.15 / $154.88
| Professional | | $61.66 | $107.15 | $154.88 |