- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.50 / $82.17 / $105.46
| Facility | | $72.50 | $82.17 | $105.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.04 / $105.46 / $105.46
| Professional | | $51.04 | $105.46 | $105.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.75 / $138.16 / $161.69
| Professional | | $104.75 | $138.16 | $161.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.88 / $105.46 / $131.82
| Professional | | $87.88 | $105.46 | $131.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.90 / $105.46 / $131.82
| Professional | | $36.90 | $105.46 | $131.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.49 / $118.64 / $166.48
| Professional | | $94.49 | $118.64 | $166.48 |