- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.93 / $24.85 / $31.90
| Facility | | $21.93 | $24.85 | $31.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.01 / $31.90 / $31.90
| Professional | | $21.01 | $31.90 | $31.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.21 / $57.00 / $66.73
| Professional | | $43.21 | $57.00 | $66.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.58 / $31.90 / $39.86
| Professional | | $26.58 | $31.90 | $39.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.16 / $31.90 / $51.60
| Professional | | $11.16 | $31.90 | $51.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.77 / $48.27 / $66.83
| Professional | | $29.77 | $48.27 | $66.83 |