- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.02 / $24.96 / $32.03
| Facility | | $22.02 | $24.96 | $32.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $32.03 / $32.03
| Professional | | $14.13 | $32.03 | $32.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.98 / $38.22 / $44.73
| Professional | | $28.98 | $38.22 | $44.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.69 / $32.03 / $40.04
| Professional | | $26.69 | $32.03 | $40.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.21 / $32.03 / $40.04
| Professional | | $11.21 | $32.03 | $40.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.13 / $33.36 / $46.71
| Professional | | $26.13 | $33.36 | $46.71 |