- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.65 / $35.65 / $35.65
| Facility | | $35.65 | $35.65 | $35.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.09 / $30.91 / $49.37
| Professional | | $27.09 | $30.91 | $49.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.87 / $46.98 / $58.79
| Professional | | $44.87 | $46.98 | $58.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.19 / $40.39 / $62.83
| Professional | | $3.19 | $40.39 | $62.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.63 / $32.24 / $49.37
| Professional | | $19.63 | $32.24 | $49.37 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.09 / $37.22 / $42.68
| Professional | | $37.09 | $37.22 | $42.68 |