- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.29 / $18.47 / $23.70
| Facility | | $16.29 | $18.47 | $23.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.33 / $23.70 / $23.70
| Professional | | $14.33 | $23.70 | $23.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.36 / $38.72 / $45.33
| Professional | | $29.36 | $38.72 | $45.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.75 / $23.70 / $29.63
| Professional | | $19.75 | $23.70 | $29.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.30 / $23.70 / $35.06
| Professional | | $8.30 | $23.70 | $35.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.12 / $32.79 / $45.41
| Professional | | $22.12 | $32.79 | $45.41 |