- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.62 / $38.02 / $46.77
| Facility | | $31.62 | $38.02 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $30.20 / $37.15
| Professional | | $10.00 | $30.20 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $46.77
| Professional | | $10.72 | $10.72 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $47.86 / $52.48
| Professional | | $38.90 | $47.86 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $46.77 / $57.54
| Professional | | $38.90 | $46.77 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $27.54 / $57.54
| Professional | | $16.22 | $27.54 | $57.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $47.86 / $69.18
| Professional | | $33.11 | $47.86 | $69.18 |