- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.04 / $19.30 / $24.78
| Facility | | $17.04 | $19.30 | $24.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.29 / $24.78 / $24.78
| Professional | | $16.29 | $24.78 | $24.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.60 / $44.32 / $51.85
| Professional | | $33.60 | $44.32 | $51.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.65 / $24.78 / $30.98
| Professional | | $20.65 | $24.78 | $30.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.67 / $24.78 / $40.09
| Professional | | $8.67 | $24.78 | $40.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.13 / $37.51 / $51.93
| Professional | | $23.13 | $37.51 | $51.93 |