- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.06 / $93.06 / $93.06
| Facility | | $93.06 | $93.06 | $93.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.47 / $55.47 / $61.02
| Professional | | $55.47 | $55.47 | $61.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.47 / $55.47 / $64.97
| Professional | | $55.47 | $55.47 | $64.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.40 / $67.40 / $67.40
| Professional | | $67.40 | $67.40 | $67.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.47 / $66.56 / $83.21
| Professional | | $55.47 | $66.56 | $83.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.22 / $58.47 / $83.21
| Professional | | $55.22 | $58.47 | $83.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.08 / $61.66 / $69.84
| Professional | | $48.08 | $61.66 | $69.84 |