- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.94 / $18.05 / $23.18
| Facility | | $15.94 | $18.05 | $23.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $23.18 / $23.18
| Professional | | $14.92 | $23.18 | $23.18 |
- 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
- $19.32 / $23.18 / $28.98
| Professional | | $19.32 | $23.18 | $28.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.11 / $23.18 / $36.71
| Professional | | $8.11 | $23.18 | $36.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.14 / $34.09 / $47.57
| Professional | | $9.14 | $34.09 | $47.57 |