- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.78 / $46.78 / $46.78
| Facility | | $46.78 | $46.78 | $46.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.18 / $21.98 / $23.63
| Professional | | $21.18 | $21.98 | $23.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.51 / $22.51 / $27.02
| Professional | | $22.51 | $22.51 | $27.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.65 / $28.65 / $28.65
| Professional | | $28.65 | $28.65 | $28.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $670.00
| Professional | | $5.00 | $5.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.87 / $22.54 / $33.11
| Professional | | $21.87 | $22.54 | $33.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.39 / $28.30 / $30.17
| Professional | | $23.39 | $28.30 | $30.17 |