- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.30 / $17.32 / $22.25
| Facility | | $15.30 | $17.32 | $22.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.72 / $22.25 / $22.25
| Professional | | $14.72 | $22.25 | $22.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.16 / $39.78 / $46.56
| Professional | | $30.16 | $39.78 | $46.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.54 / $22.25 / $27.81
| Professional | | $18.54 | $22.25 | $27.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.79 / $22.25 / $35.97
| Professional | | $7.79 | $22.25 | $35.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.76 / $33.68 / $46.64
| Professional | | $20.76 | $33.68 | $46.64 |