- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.83 / $23.61 / $30.30
| Facility | | $20.83 | $23.61 | $30.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.48 / $29.48 / $29.48
| Professional | | $29.48 | $29.48 | $29.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.02 / $30.30 / $30.30
| Professional | | $20.02 | $30.30 | $30.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.04 / $54.14 / $63.39
| Professional | | $41.04 | $54.14 | $63.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.25 / $30.30 / $37.88
| Professional | | $25.25 | $30.30 | $37.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.61 / $30.30 / $49.02
| Professional | | $10.61 | $30.30 | $49.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.28 / $45.86 / $63.50
| Professional | | $28.28 | $45.86 | $63.50 |