- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.39 / $26.92 / $32.36
| Facility | | $22.39 | $26.92 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $25.12 / $25.70
| Professional | | $19.05 | $25.12 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $21.38 / $32.36
| Professional | | $21.38 | $21.38 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $42.66 / $47.86
| Professional | | $33.11 | $42.66 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $32.36 / $40.74
| Professional | | $26.92 | $32.36 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $32.36 / $52.48
| Professional | | $11.48 | $32.36 | $52.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $42.66 / $61.66
| Professional | | $32.36 | $42.66 | $61.66 |