- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.17 / $72.72 / $93.34
| Facility | | $64.17 | $72.72 | $93.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.78 / $77.78 / $77.78
| Professional | | $77.78 | $77.78 | $77.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.84 / $93.34 / $93.34
| Professional | | $29.84 | $93.34 | $93.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.22 / $81.44 / $91.78
| Professional | | $69.22 | $81.44 | $91.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.78 / $93.34 / $116.67
| Professional | | $77.78 | $93.34 | $116.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.67 / $93.34 / $116.67
| Professional | | $32.67 | $93.34 | $116.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.11 / $87.11 / $125.91
| Professional | | $66.11 | $87.11 | $125.91 |