- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.82 / $36.06 / $46.28
| Facility | | $31.82 | $36.06 | $46.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.28 / $46.28 / $46.28
| Professional | | $46.28 | $46.28 | $46.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.33 / $40.39 / $48.21
| Professional | | $34.33 | $40.39 | $48.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.57 / $46.28 / $57.86
| Professional | | $38.57 | $46.28 | $57.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.20 / $46.28 / $57.86
| Professional | | $16.20 | $46.28 | $57.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.78 / $52.07 / $86.78
| Professional | | $32.78 | $52.07 | $86.78 |