- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.20 / $25.16 / $32.29
| Facility | | $22.20 | $25.16 | $32.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.70 / $14.70 / $14.70
| Professional | | $14.70 | $14.70 | $14.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.12 / $32.29 / $32.29
| Professional | | $15.12 | $32.29 | $32.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.79 / $38.70 / $45.10
| Professional | | $32.79 | $38.70 | $45.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.60 / $32.29 / $37.67
| Professional | | $29.60 | $32.29 | $37.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.29 / $32.29 / $40.36
| Professional | | $32.29 | $32.29 | $40.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.91 / $34.97 / $49.10
| Professional | | $26.91 | $34.97 | $49.10 |