- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.48 / $20.95 / $26.89
| Facility | | $18.48 | $20.95 | $26.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.31 / $26.89 / $26.89
| Professional | | $15.31 | $26.89 | $26.89 |
- 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
- $22.41 / $26.89 / $33.61
| Professional | | $22.41 | $26.89 | $33.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.41 / $26.89 / $33.61
| Professional | | $9.41 | $26.89 | $33.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.02 / $27.72 / $41.81
| Professional | | $21.02 | $27.72 | $41.81 |