- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.16 / $56.85 / $72.95
| Facility | | $50.16 | $56.85 | $72.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $72.95 / $72.95
| Professional | | $9.42 | $72.95 | $72.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.73 / $31.53 / $63.66
| Professional | | $25.73 | $31.53 | $63.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.80 / $72.95 / $91.20
| Professional | | $60.80 | $72.95 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.76 / $72.95 / $91.20
| Professional | | $16.76 | $72.95 | $91.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $29.33 / $89.38
| Professional | | $18.44 | $29.33 | $89.38 |