- 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
- $33.95 / $33.95 / $34.20
| Professional | | $33.95 | $33.95 | $34.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.84 / $45.28 / $45.28
| Professional | | $29.84 | $45.28 | $45.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.94 / $73.56 / $89.51
| Professional | | $57.94 | $73.56 | $89.51 |
- 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
- $15.85 / $45.28 / $73.23
| Professional | | $15.85 | $45.28 | $73.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.26 / $69.45 / $94.86
| Professional | | $42.26 | $69.45 | $94.86 |