- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.89 / $73.54 / $94.38
| Facility | | $64.89 | $73.54 | $94.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.41 / $94.38 / $94.38
| Professional | | $31.41 | $94.38 | $94.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.01 / $79.89 / $88.47
| Professional | | $70.01 | $79.89 | $88.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.65 / $94.38 / $117.98
| Professional | | $78.65 | $94.38 | $117.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.03 / $65.38 / $94.38
| Professional | | $33.03 | $65.38 | $94.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.74 / $73.84 / $115.62
| Professional | | $51.74 | $73.84 | $115.62 |