- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.43 / $48.09 / $61.72
| Facility | | $42.43 | $48.09 | $61.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.72 / $61.72 / $61.72
| Professional | | $61.72 | $61.72 | $61.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.77 / $53.85 / $64.29
| Professional | | $45.77 | $53.85 | $64.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.43 / $61.72 / $77.15
| Professional | | $51.43 | $61.72 | $77.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.56 / $61.72 / $61.72
| Professional | | $44.56 | $61.72 | $61.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.43 / $69.43 / $75.59
| Professional | | $69.43 | $69.43 | $75.59 |