- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.05 / $26.12 / $33.53
| Facility | | $23.05 | $26.12 | $33.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.51 / $14.51 / $27.94
| Professional | | $14.51 | $14.51 | $27.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.71 / $33.53 / $33.53
| Professional | | $15.71 | $33.53 | $33.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.90 / $54.47 / $66.28
| Professional | | $42.90 | $54.47 | $66.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.94 / $33.53 / $41.91
| Professional | | $27.94 | $33.53 | $41.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.73 / $33.53 / $41.91
| Professional | | $11.73 | $33.53 | $41.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.75 / $37.44 / $62.87
| Professional | | $23.75 | $37.44 | $62.87 |