- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.03 / $15.90 / $20.39
| Facility | | $14.03 | $15.90 | $20.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.39 / $20.39
| Professional | | $13.35 | $20.39 | $20.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.28 / $35.99 / $42.15
| Professional | | $27.28 | $35.99 | $42.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.39 / $25.50
| Professional | | $17.00 | $20.39 | $25.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.14 / $20.39 / $32.56
| Professional | | $7.14 | $20.39 | $32.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.04 / $30.47 / $42.19
| Professional | | $19.04 | $30.47 | $42.19 |