- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.58 / $38.04 / $48.84
| Facility | | $33.58 | $38.04 | $48.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.80 / $16.80 / $16.80
| Professional | | $16.80 | $16.80 | $16.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.20 / $48.84 / $48.84
| Professional | | $21.20 | $48.84 | $48.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.20 / $54.52 / $63.53
| Professional | | $46.20 | $54.52 | $63.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.77 / $48.84 / $56.98
| Professional | | $44.77 | $48.84 | $56.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.39 / $48.84 / $61.05
| Professional | | $48.39 | $48.84 | $61.05 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.92 / $50.13 / $71.23
| Professional | | $37.92 | $50.13 | $71.23 |