- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.46 / $28.85 / $37.03
| Facility | | $25.46 | $28.85 | $37.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.26 / $37.03 / $37.03
| Professional | | $18.26 | $37.03 | $37.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.25 / $44.75 / $54.45
| Professional | | $35.25 | $44.75 | $54.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.86 / $37.03 / $46.29
| Professional | | $30.86 | $37.03 | $46.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.96 / $37.03 / $46.29
| Professional | | $12.96 | $37.03 | $46.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.23 / $42.25 / $69.44
| Professional | | $26.23 | $42.25 | $69.44 |