- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.35 / $18.53 / $23.78
| Facility | | $16.35 | $18.53 | $23.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.56 / $23.78 / $23.78
| Professional | | $12.56 | $23.78 | $23.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.87 / $34.13 / $39.89
| Professional | | $25.87 | $34.13 | $39.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.82 / $23.78 / $29.73
| Professional | | $19.82 | $23.78 | $29.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $23.78 / $30.88
| Professional | | $8.32 | $23.78 | $30.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.20 / $29.14 / $41.11
| Professional | | $22.20 | $29.14 | $41.11 |