- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.45 / $45.84 / $58.84
| Facility | | $40.45 | $45.84 | $58.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.07 / $125.07 / $125.07
| Professional | | $125.07 | $125.07 | $125.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.86 / $58.84 / $58.84
| Professional | | $38.86 | $58.84 | $58.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.73 / $105.16 / $123.04
| Professional | | $79.73 | $105.16 | $123.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.03 / $58.84 / $73.55
| Professional | | $49.03 | $58.84 | $73.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.59 / $58.84 / $95.18
| Professional | | $20.59 | $58.84 | $95.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.91 / $89.04 / $123.28
| Professional | | $54.91 | $89.04 | $123.28 |