- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.09 / $25.04 / $32.14
| Facility | | $22.09 | $25.04 | $32.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.96 / $30.96 / $36.77
| Professional | | $30.96 | $30.96 | $36.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.20 / $32.14 / $32.14
| Professional | | $21.20 | $32.14 | $32.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.77 / $35.26 / $42.90
| Professional | | $27.77 | $35.26 | $42.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.78 / $32.14 / $40.17
| Professional | | $26.78 | $32.14 | $40.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.25 / $32.14 / $40.17
| Professional | | $11.25 | $32.14 | $40.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.76 / $36.15 / $57.86
| Professional | | $22.76 | $36.15 | $57.86 |