- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.00 / $31.73 / $40.72
| Facility | | $28.00 | $31.73 | $40.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.89 / $40.72 / $40.72
| Professional | | $26.89 | $40.72 | $40.72 |
- 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
- $33.94 / $40.72 / $50.91
| Professional | | $33.94 | $40.72 | $50.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.25 / $40.72 / $65.89
| Professional | | $14.25 | $40.72 | $65.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.01 / $61.66 / $85.37
| Professional | | $38.01 | $61.66 | $85.37 |