- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.74 / $40.74 / $40.74
| Facility | | $40.74 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $22.91 / $28.84
| Professional | | $1.00 | $22.91 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.95 / $1.95 / $1.95
| Professional | | $1.95 | $1.95 | $1.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $37.15 / $41.69
| Professional | | $30.20 | $37.15 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $36.31 / $44.67
| Professional | | $30.20 | $36.31 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.63 / $5.01 / $44.67
| Professional | | $3.63 | $5.01 | $44.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.80 / $4.47 / $5.13
| Professional | | $3.80 | $4.47 | $5.13 |