- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.60 / $25.61 / $32.86
| Facility | | $22.60 | $25.61 | $32.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.90 / $32.86 / $32.86
| Professional | | $15.90 | $32.86 | $32.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.71 / $43.13 / $50.47
| Professional | | $32.71 | $43.13 | $50.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.39 / $32.86 / $41.09
| Professional | | $27.39 | $32.86 | $41.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.50 / $32.86 / $41.09
| Professional | | $11.50 | $32.86 | $41.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.49 / $37.02 / $51.97
| Professional | | $29.49 | $37.02 | $51.97 |