- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.50 / $45.50 / $45.50
| Facility | | $45.50 | $45.50 | $45.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.47 / $134.44 / $192.63
| Professional | | $88.47 | $134.44 | $192.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.13 / $138.09 / $208.27
| Professional | | $88.13 | $138.09 | $208.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.25 / $150.28 / $176.64
| Professional | | $135.25 | $150.28 | $176.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $670.00 / $670.00
| Professional | | $670.00 | $670.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.60 / $160.55 / $204.69
| Professional | | $111.60 | $160.55 | $204.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.98 / $116.52 / $304.80
| Professional | | $61.98 | $116.52 | $304.80 |