- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.45 / $43.57 / $55.92
| Facility | | $38.45 | $43.57 | $55.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.13 / $44.13 / $44.13
| Professional | | $44.13 | $44.13 | $44.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.92 / $55.92 / $55.92
| Professional | | $55.92 | $55.92 | $55.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $70.80 / $82.50
| Professional | | $60.00 | $70.80 | $82.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.26 / $55.92 / $65.23
| Professional | | $51.26 | $55.92 | $65.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.92 / $58.40 / $83.09
| Professional | | $55.92 | $58.40 | $83.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.61 / $68.50 / $104.85
| Professional | | $39.61 | $68.50 | $104.85 |