- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.07 / $79.43 / $95.50
| Facility | | $66.07 | $79.43 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $61.66 / $77.62
| Professional | | $6.03 | $61.66 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.92 / $6.92 / $95.50
| Professional | | $6.92 | $6.92 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $100.00 / $109.65
| Professional | | $81.28 | $100.00 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $95.50 / $120.23
| Professional | | $81.28 | $95.50 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $33.88 / $120.23
| Professional | | $12.02 | $33.88 | $120.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.18 / $20.89 / $125.89
| Professional | | $13.18 | $20.89 | $125.89 |