- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.91 / $30.50 / $39.14
| Facility | | $26.91 | $30.50 | $39.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.72 / $44.79 / $255.00
| Professional | | $37.72 | $44.79 | $255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.14 / $39.14 / $40.44
| Professional | | $39.14 | $39.14 | $40.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.01 / $69.92 / $81.84
| Professional | | $53.01 | $69.92 | $81.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.61 / $39.14 / $48.93
| Professional | | $32.61 | $39.14 | $48.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.70 / $39.14 / $63.31
| Professional | | $13.70 | $39.14 | $63.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.53 / $59.23 / $82.01
| Professional | | $36.53 | $59.23 | $82.01 |