- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $57.54 / $70.79
| Facility | | $47.86 | $57.54 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.90 / $50.12 / $72.44
| Professional | | $30.90 | $50.12 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $33.88 / $70.79
| Professional | | $30.20 | $33.88 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $95.50 / $104.71
| Professional | | $74.13 | $95.50 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $70.79 / $87.10
| Professional | | $64.57 | $70.79 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $60.26 / $87.10
| Professional | | $22.91 | $60.26 | $87.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $79.43 / $109.65
| Professional | | $63.10 | $79.43 | $109.65 |