- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.94 / $45.94 / $45.94
| Facility | | $45.94 | $45.94 | $45.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.01 / $22.23 / $3,374.35
| Professional | | $22.01 | $22.23 | $3,374.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.02 / $22.02 / $22.02
| Professional | | $22.02 | $22.02 | $22.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Professional | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.22 / $26.42 / $30.83
| Professional | | $24.22 | $26.42 | $30.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.02 / $24.93 / $33.03
| Professional | | $22.02 | $24.93 | $33.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.71 / $25.13 / $29.30
| Professional | | $22.71 | $25.13 | $29.30 |