- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.33 / $25.31 / $32.47
| Facility | | $22.33 | $25.31 | $32.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.87 / $32.47 / $32.47
| Professional | | $6.87 | $32.47 | $32.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.46 / $22.59 / $28.35
| Professional | | $18.46 | $22.59 | $28.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.07 / $32.47 / $40.61
| Professional | | $27.07 | $32.47 | $40.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.37 / $32.47 / $40.61
| Professional | | $11.37 | $32.47 | $40.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.23 / $19.85 / $39.79
| Professional | | $13.23 | $19.85 | $39.79 |