- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.22 / $22.92 / $29.41
| Facility | | $20.22 | $22.92 | $29.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.43 / $29.41 / $29.41
| Professional | | $19.43 | $29.41 | $29.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.82 / $52.52 / $61.49
| Professional | | $39.82 | $52.52 | $61.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.51 / $29.41 / $36.77
| Professional | | $24.51 | $29.41 | $36.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.29 / $29.41 / $47.57
| Professional | | $10.29 | $29.41 | $47.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.45 / $44.50 / $61.61
| Professional | | $27.45 | $44.50 | $61.61 |