- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.55 / $64.09 / $82.26
| Facility | | $56.55 | $64.09 | $82.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.56 / $31.56 / $31.56
| Professional | | $31.56 | $31.56 | $31.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.26 / $82.26 / $82.26
| Professional | | $82.26 | $82.26 | $82.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.12 / $74.58 / $82.50
| Professional | | $67.12 | $74.58 | $82.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.41 / $82.26 / $95.97
| Professional | | $75.41 | $82.26 | $95.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.55 / $82.26 / $102.83
| Professional | | $59.55 | $82.26 | $102.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.27 / $85.69 / $145.68
| Professional | | $58.27 | $85.69 | $145.68 |