- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.13 / $35.28 / $45.28
| Facility | | $31.13 | $35.28 | $45.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.90 / $51.81 / $236.00
| Professional | | $9.90 | $51.81 | $236.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.28 / $45.28 / $45.28
| Professional | | $45.28 | $45.28 | $45.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.51 / $23.50 / $28.60
| Professional | | $18.51 | $23.50 | $28.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.72 / $45.28 / $56.60
| Professional | | $37.72 | $45.28 | $56.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.05 / $45.28 / $45.28
| Professional | | $12.05 | $45.28 | $45.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.26 / $32.07 / $84.89
| Professional | | $13.26 | $32.07 | $84.89 |