- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.55 / $19.89 / $25.52
| Facility | | $17.55 | $19.89 | $25.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.12 / $25.52 / $25.52
| Professional | | $15.12 | $25.52 | $25.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.10 / $41.02 / $48.01
| Professional | | $31.10 | $41.02 | $48.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.27 / $25.52 / $31.91
| Professional | | $21.27 | $25.52 | $31.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.93 / $25.52 / $37.14
| Professional | | $8.93 | $25.52 | $37.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.82 / $34.75 / $48.11
| Professional | | $23.82 | $34.75 | $48.11 |