- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.70 / $63.10 / $77.62
| Facility | | $53.70 | $63.10 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $60.26 / $61.66
| Professional | | $45.71 | $60.26 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $51.29 / $77.62
| Professional | | $51.29 | $51.29 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $144.54 / $158.49
| Professional | | $112.20 | $144.54 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $77.62 / $97.72
| Professional | | $64.57 | $77.62 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $89.13 / $125.89
| Professional | | $26.92 | $89.13 | $125.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $117.49 / $162.18
| Professional | | $72.44 | $117.49 | $162.18 |