- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.64 / $30.64 / $30.64
| Facility | | $30.64 | $30.64 | $30.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.93 / $27.85 / $45.00
| Professional | | $26.93 | $27.85 | $45.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.05 / $18.05 / $18.05
| Professional | | $18.05 | $18.05 | $18.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.59 / $41.47 / $48.49
| Professional | | $34.59 | $41.47 | $48.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.77 / $39.32 / $49.16
| Professional | | $32.77 | $39.32 | $49.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.76 / $39.32 / $49.16
| Professional | | $13.76 | $39.32 | $49.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.91 / $43.91 / $43.91
| Professional | | $43.91 | $43.91 | $43.91 |