- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.44 / $23.44 / $33.88
| Facility | | $23.44 | $23.44 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $21.88 / $23.99
| Professional | | $18.20 | $21.88 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $19.95 / $19.95
| Professional | | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $54.95 / $61.66
| Professional | | $42.66 | $54.95 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $30.20 / $37.15
| Professional | | $25.12 | $30.20 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $34.67 / $37.15
| Professional | | $10.47 | $34.67 | $37.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $42.66 / $50.12
| Professional | | $36.31 | $42.66 | $50.12 |