- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.90 / $119.90 / $119.90
| Facility | | $119.90 | $119.90 | $119.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.25 / $86.65 / $173.26
| Professional | | $72.25 | $86.65 | $173.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.78 / $93.78 / $93.78
| Professional | | $93.78 | $93.78 | $93.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.30 / $90.30 / $90.30
| Professional | | $90.30 | $90.30 | $90.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.17 / $88.55 / $103.31
| Professional | | $81.17 | $88.55 | $103.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.93 / $98.84 / $127.41
| Professional | | $85.93 | $98.84 | $127.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.91 / $80.53 / $90.46
| Professional | | $62.91 | $80.53 | $90.46 |