- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.85 / $54.23 / $69.59
| Facility | | $47.85 | $54.23 | $69.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.42 / $23.42 / $23.42
| Professional | | $23.42 | $23.42 | $23.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.90 / $69.59 / $69.59
| Professional | | $15.90 | $69.59 | $69.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.01 / $51.62 / $60.73
| Professional | | $43.01 | $51.62 | $60.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.80 / $69.59 / $81.20
| Professional | | $63.80 | $69.59 | $81.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.02 / $69.59 / $87.00
| Professional | | $28.02 | $69.59 | $87.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.82 / $46.23 / $85.26
| Professional | | $30.82 | $46.23 | $85.26 |