- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.36 / $54.81 / $70.34
| Facility | | $48.36 | $54.81 | $70.34 |
- 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 / $70.34 / $70.34
| Professional | | $33.96 | $70.34 | $70.34 |
- 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
- $64.48 / $70.34 / $82.07
| Professional | | $64.48 | $70.34 | $82.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.85 / $70.34 / $87.93
| Professional | | $59.85 | $70.34 | $87.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.84 / $78.87 / $110.72
| Professional | | $62.84 | $78.87 | $110.72 |