- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.93 / $31.66 / $40.63
| Facility | | $27.93 | $31.66 | $40.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.17 / $39.17 / $46.49
| Professional | | $39.17 | $39.17 | $46.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.89 / $40.63 / $40.63
| Professional | | $26.89 | $40.63 | $40.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.95 / $65.88 / $77.08
| Professional | | $49.95 | $65.88 | $77.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.86 / $40.63 / $50.79
| Professional | | $33.86 | $40.63 | $50.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.22 / $40.63 / $59.64
| Professional | | $14.22 | $40.63 | $59.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.92 / $55.80 / $77.26
| Professional | | $37.92 | $55.80 | $77.26 |