- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.20 / $22.89 / $29.38
| Facility | | $20.20 | $22.89 | $29.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $29.38 / $29.38
| Professional | | $10.40 | $29.38 | $29.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.07 / $28.28 / $33.09
| Professional | | $23.07 | $28.28 | $33.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.48 / $29.38 / $36.72
| Professional | | $24.48 | $29.38 | $36.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.28 / $29.38 / $36.72
| Professional | | $10.28 | $29.38 | $36.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.05 / $28.02 / $42.84
| Professional | | $20.05 | $28.02 | $42.84 |