- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.23 / $70.23 / $70.23
| Facility | | $70.23 | $70.23 | $70.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.54 / $50.10 / $86.27
| Professional | | $41.54 | $50.10 | $86.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.43 / $82.13 / $102.42
| Professional | | $78.43 | $82.13 | $102.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.90 / $70.59 / $109.80
| Professional | | $54.90 | $70.59 | $109.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.38 / $70.23 / $86.27
| Professional | | $32.38 | $70.23 | $86.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.64 / $68.28 / $78.43
| Professional | | $64.64 | $68.28 | $78.43 |