- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.65 / $30.20 / $38.76
| Facility | | $26.65 | $30.20 | $38.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.52 / $38.76 / $38.76
| Professional | | $25.52 | $38.76 | $38.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.54 / $69.30 / $81.09
| Professional | | $52.54 | $69.30 | $81.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.29 / $38.76 / $48.45
| Professional | | $32.29 | $38.76 | $48.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.57 / $38.76 / $62.70
| Professional | | $13.57 | $38.76 | $62.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.18 / $58.67 / $81.23
| Professional | | $36.18 | $58.67 | $81.23 |