- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.26 / $44.50 / $57.11
| Facility | | $39.26 | $44.50 | $57.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.69 / $57.11 / $57.11
| Professional | | $37.69 | $57.11 | $57.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.28 / $65.01 / $76.08
| Professional | | $49.28 | $65.01 | $76.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.59 / $57.11 / $71.39
| Professional | | $47.59 | $57.11 | $71.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.98 / $57.11 / $71.39
| Professional | | $19.98 | $57.11 | $71.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.47 / $58.65 / $101.19
| Professional | | $44.47 | $58.65 | $101.19 |