- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.94 / $25.99 / $33.36
| Facility | | $22.94 | $25.99 | $33.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.73 / $24.73 / $24.73
| Professional | | $24.73 | $24.73 | $24.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.99 / $33.36 / $33.36
| Professional | | $21.99 | $33.36 | $33.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.23 / $59.66 / $69.83
| Professional | | $45.23 | $59.66 | $69.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.80 / $33.36 / $41.70
| Professional | | $27.80 | $33.36 | $41.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.68 / $33.36 / $53.96
| Professional | | $11.68 | $33.36 | $53.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.14 / $50.51 / $69.93
| Professional | | $31.14 | $50.51 | $69.93 |