- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.37 / $25.35 / $32.53
| Facility | | $22.37 | $25.35 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.31 / $32.53 / $32.53
| Professional | | $15.31 | $32.53 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.73 / $35.20 / $42.84
| Professional | | $27.73 | $35.20 | $42.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.11 / $32.53 / $40.67
| Professional | | $27.11 | $32.53 | $40.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.39 / $32.53 / $40.67
| Professional | | $11.39 | $32.53 | $40.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.04 / $36.60 / $61.00
| Professional | | $23.04 | $36.60 | $61.00 |