- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.00 / $23.80 / $30.54
| Facility | | $21.00 | $23.80 | $30.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.42 / $69.23 / $84.00
| Professional | | $30.42 | $69.23 | $84.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.22 / $30.54 / $30.54
| Professional | | $20.22 | $30.54 | $30.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.37 / $54.57 / $63.88
| Professional | | $41.37 | $54.57 | $63.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.45 / $30.54 / $38.18
| Professional | | $25.45 | $30.54 | $38.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.69 / $30.54 / $49.39
| Professional | | $10.69 | $30.54 | $49.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.50 / $46.20 / $63.97
| Professional | | $28.50 | $46.20 | $63.97 |