- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.17 / $34.19 / $43.88
| Facility | | $30.17 | $34.19 | $43.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.05 / $43.88 / $43.88
| Professional | | $29.05 | $43.88 | $43.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.46 / $78.43 / $91.81
| Professional | | $59.46 | $78.43 | $91.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.57 / $43.88 / $54.86
| Professional | | $36.57 | $43.88 | $54.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.36 / $43.88 / $70.98
| Professional | | $15.36 | $43.88 | $70.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.96 / $66.42 / $91.96
| Professional | | $40.96 | $66.42 | $91.96 |