- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.71 / $225.60 / $375.30
| Facility | | $36.71 | $225.60 | $375.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.26 / $40.60 / $58.50
| Professional | | $39.26 | $40.60 | $58.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.89 / $26.89 / $26.89
| Professional | | $26.89 | $26.89 | $26.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.22 / $72.84 / $85.21
| Professional | | $55.22 | $72.84 | $85.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.26 / $47.11 / $54.96
| Professional | | $39.26 | $47.11 | $54.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $47.11 / $65.89
| Professional | | $16.48 | $47.11 | $65.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.77 / $46.80 / $63.56
| Professional | | $36.77 | $46.80 | $63.56 |