- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.99 / $52.12 / $66.89
| Facility | | $45.99 | $52.12 | $66.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.29 / $32.29 / $32.29
| Professional | | $32.29 | $32.29 | $32.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.18 / $66.89 / $66.89
| Professional | | $33.18 | $66.89 | $66.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.90 / $85.02 / $99.08
| Professional | | $67.90 | $85.02 | $99.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.31 / $66.89 / $78.04
| Professional | | $61.31 | $66.89 | $78.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.33 / $66.89 / $83.61
| Professional | | $58.33 | $66.89 | $83.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.25 / $76.87 / $107.91
| Professional | | $61.25 | $76.87 | $107.91 |