- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.96 / $47.55 / $61.03
| Facility | | $41.96 | $47.55 | $61.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.89 / $61.03 / $61.03
| Professional | | $26.89 | $61.03 | $61.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.79 / $43.23 / $53.26
| Professional | | $27.79 | $43.23 | $53.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.86 / $61.03 / $76.29
| Professional | | $50.86 | $61.03 | $76.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.91 / $61.03 / $65.89
| Professional | | $18.91 | $61.03 | $65.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.09 / $74.76 / $114.44
| Professional | | $33.09 | $74.76 | $114.44 |