- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.76 / $39.39 / $50.56
| Facility | | $34.76 | $39.39 | $50.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.13 / $42.13 / $57.60
| Professional | | $42.13 | $42.13 | $57.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.32 / $50.56 / $50.56
| Professional | | $25.32 | $50.56 | $50.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.50 / $44.12 / $52.66
| Professional | | $37.50 | $44.12 | $52.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.13 / $50.56 / $63.20
| Professional | | $42.13 | $50.56 | $63.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.69 / $50.56 / $63.20
| Professional | | $17.69 | $50.56 | $63.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.81 / $56.88 / $94.79
| Professional | | $35.81 | $56.88 | $94.79 |