- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.09 / $49.09 / $49.09
| Facility | | $49.09 | $49.09 | $49.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.06 / $46.90 / $67.00
| Professional | | $39.06 | $46.90 | $67.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.39 / $48.58 / $79.25
| Professional | | $46.39 | $48.58 | $79.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.51 / $54.66 / $85.02
| Professional | | $42.51 | $54.66 | $85.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.69 / $49.09 / $67.00
| Professional | | $27.69 | $49.09 | $67.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $51.32 / $57.53
| Professional | | $50.00 | $51.32 | $57.53 |