- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.28 / $19.57 / $25.13
| Facility | | $17.28 | $19.57 | $25.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $25.13 / $25.13
| Professional | | $14.92 | $25.13 | $25.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.27 / $30.70 / $36.00
| Professional | | $23.27 | $30.70 | $36.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.94 / $25.13 / $31.41
| Professional | | $20.94 | $25.13 | $31.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.78 / $25.13 / $31.41
| Professional | | $8.78 | $25.13 | $31.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.02 / $26.83 / $40.69
| Professional | | $21.02 | $26.83 | $40.69 |