- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.18 / $16.07 / $20.63
| Facility | | $14.18 | $16.07 | $20.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.55 / $20.63 / $20.63
| Professional | | $13.55 | $20.63 | $20.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.95 / $36.86 / $43.13
| Professional | | $27.95 | $36.86 | $43.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.19 / $20.63 / $25.79
| Professional | | $17.19 | $20.63 | $25.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.22 / $20.63 / $33.36
| Professional | | $7.22 | $20.63 | $33.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.25 / $31.23 / $43.24
| Professional | | $19.25 | $31.23 | $43.24 |