- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.78 / $26.96 / $34.60
| Facility | | $23.78 | $26.96 | $34.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.77 / $34.60 / $34.60
| Professional | | $22.77 | $34.60 | $34.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.88 / $61.84 / $72.38
| Professional | | $46.88 | $61.84 | $72.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.83 / $34.60 / $43.25
| Professional | | $28.83 | $34.60 | $43.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.11 / $34.60 / $55.97
| Professional | | $12.11 | $34.60 | $55.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.29 / $52.38 / $72.52
| Professional | | $32.29 | $52.38 | $72.52 |