- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.47 / $45.47 / $47.31
| Professional | | $45.47 | $45.47 | $47.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.98 / $127.98 / $127.98
| Facility | | $127.98 | $127.98 | $127.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $48.98 / $177.20
| Professional | | $48.98 | $48.98 | $177.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.09 / $168.68 / $168.68
| Professional | | $161.09 | $168.68 | $168.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.65 / $161.09 / $225.53
| Professional | | $96.65 | $161.09 | $225.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.82 / $127.98 / $177.20
| Professional | | $57.82 | $127.98 | $177.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.45 / $129.77 / $153.32
| Professional | | $70.45 | $129.77 | $153.32 |