- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.79 / $45.10 / $57.89
| Facility | | $39.79 | $45.10 | $57.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.16 / $27.16 / $27.16
| Professional | | $27.16 | $27.16 | $27.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.88 / $57.89 / $57.89
| Professional | | $27.88 | $57.89 | $57.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.06 / $71.45 / $83.26
| Professional | | $57.06 | $71.45 | $83.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.06 / $57.89 / $67.54
| Professional | | $53.06 | $57.89 | $67.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.04 / $57.89 / $72.36
| Professional | | $49.04 | $57.89 | $72.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.24 / $64.62 / $90.72
| Professional | | $48.24 | $64.62 | $90.72 |