- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.53 / $68.59 / $88.04
| Facility | | $60.53 | $68.59 | $88.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.97 / $39.97 / $39.97
| Professional | | $39.97 | $39.97 | $39.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.23 / $88.04 / $88.04
| Professional | | $41.23 | $88.04 | $88.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.00 / $99.12 / $115.50
| Professional | | $84.00 | $99.12 | $115.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.70 / $88.04 / $102.72
| Professional | | $80.70 | $88.04 | $102.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.44 / $88.04 / $110.06
| Professional | | $75.44 | $88.04 | $110.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.36 / $107.85 / $165.08
| Professional | | $62.36 | $107.85 | $165.08 |