- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.70 / $59.70 / $59.70
| Facility | | $59.70 | $59.70 | $59.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $39.00 / $60.73
| Professional | | $14.40 | $39.00 | $60.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.70 / $59.70 / $59.70
| Facility | | $59.70 | $59.70 | $59.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $55.92 / $94.57
| Professional | | $6.00 | $55.92 | $94.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.08 / $65.31 / $82.75
| Professional | | $56.08 | $65.31 | $82.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.90 / $57.99 / $108.20
| Professional | | $42.90 | $57.99 | $108.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $250.00 / $257.50
| Professional | | $120.00 | $250.00 | $257.50 |