- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.73 / $79.73 / $79.73
| Facility | | $79.73 | $79.73 | $79.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.73 / $79.73 / $79.73
| Facility | | $79.73 | $79.73 | $79.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.00 / $54.00 / $54.00
| Professional | | $54.00 | $54.00 | $54.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.43 / $60.43 / $60.43
| Professional | | $60.43 | $60.43 | $60.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.04 / $59.29 / $79.41
| Professional | | $51.04 | $59.29 | $79.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.38 / $42.10 / $53.57
| Professional | | $40.38 | $42.10 | $53.57 |