- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.34 / $40.06 / $51.41
| Facility | | $35.34 | $40.06 | $51.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.15 / $33.15 / $33.15
| Professional | | $33.15 | $33.15 | $33.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.96 / $51.41 / $51.41
| Professional | | $33.96 | $51.41 | $51.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.64 / $87.20 / $101.61
| Professional | | $69.64 | $87.20 | $101.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.12 / $51.41 / $59.98
| Professional | | $47.12 | $51.41 | $59.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.41 / $64.26 / $64.26
| Professional | | $51.41 | $64.26 | $64.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.98 / $77.20 / $107.73
| Professional | | $47.98 | $77.20 | $107.73 |