- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.76 / $66.59 / $85.48
| Facility | | $58.76 | $66.59 | $85.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.42 / $85.48 / $85.48
| Professional | | $41.42 | $85.48 | $85.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.10 / $112.24 / $131.36
| Professional | | $85.10 | $112.24 | $131.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.23 / $85.48 / $106.85
| Professional | | $71.23 | $85.48 | $106.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.92 / $85.48 / $106.85
| Professional | | $29.92 | $85.48 | $106.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.78 / $96.37 / $135.27
| Professional | | $76.78 | $96.37 | $135.27 |