- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.70 / $30.90 / $37.15
| Facility | | $25.70 | $30.90 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $28.84 / $30.20
| Professional | | $12.02 | $28.84 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $24.55 / $37.15
| Professional | | $24.55 | $24.55 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $69.18 / $75.86
| Professional | | $53.70 | $69.18 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.90 / $37.15 / $46.77
| Professional | | $30.90 | $37.15 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $43.65 / $60.26
| Professional | | $12.88 | $43.65 | $60.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $56.23 / $77.62
| Professional | | $34.67 | $56.23 | $77.62 |