- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.60 / $17.68 / $22.69
| Facility | | $15.60 | $17.68 | $22.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $22.69 / $22.69
| Professional | | $14.92 | $22.69 | $22.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.93 / $32.88 / $47.49
| Professional | | $24.93 | $32.88 | $47.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.91 / $22.69 / $28.37
| Professional | | $18.91 | $22.69 | $28.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $22.69 / $36.71
| Professional | | $7.94 | $22.69 | $36.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.07 / $34.09 / $47.57
| Professional | | $16.07 | $34.09 | $47.57 |