- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.51 / $41.37 / $53.10
| Facility | | $36.51 | $41.37 | $53.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.75 / $31.75 / $31.75
| Professional | | $31.75 | $31.75 | $31.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.21 / $53.10 / $53.10
| Professional | | $10.21 | $53.10 | $53.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.79 / $37.61 / $46.34
| Professional | | $27.79 | $37.61 | $46.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.25 / $53.10 / $66.38
| Professional | | $44.25 | $53.10 | $66.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.80 / $53.10 / $66.38
| Professional | | $17.80 | $53.10 | $66.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.61 / $59.74 / $79.65
| Professional | | $37.61 | $59.74 | $79.65 |