- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.52 / $25.53 / $32.76
| Facility | | $22.52 | $25.53 | $32.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.55 / $32.76 / $32.76
| Professional | | $13.55 | $32.76 | $32.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.95 / $36.86 / $43.13
| Professional | | $27.95 | $36.86 | $43.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.30 / $32.76 / $40.95
| Professional | | $27.30 | $32.76 | $40.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.47 / $32.76 / $40.95
| Professional | | $11.47 | $32.76 | $40.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.22 / $34.13 / $47.78
| Professional | | $25.22 | $34.13 | $47.78 |