- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.74 / $57.50 / $73.80
| Facility | | $50.74 | $57.50 | $73.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.13 / $40.13 / $40.13
| Professional | | $40.13 | $40.13 | $40.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.29 / $73.80 / $73.80
| Professional | | $27.29 | $73.80 | $73.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.96 / $73.70 / $86.28
| Professional | | $57.96 | $73.70 | $86.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.50 / $73.80 / $92.25
| Professional | | $61.50 | $73.80 | $92.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.83 / $73.80 / $92.25
| Professional | | $25.83 | $73.80 | $92.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.23 / $72.56 / $107.63
| Professional | | $52.23 | $72.56 | $107.63 |