- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.08 / $17.09 / $21.94
| Facility | | $15.08 | $17.09 | $21.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.53 / $21.94 / $21.94
| Professional | | $14.53 | $21.94 | $21.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.74 / $39.22 / $45.91
| Professional | | $29.74 | $39.22 | $45.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.28 / $21.94 / $27.42
| Professional | | $18.28 | $21.94 | $27.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.68 / $21.94 / $35.47
| Professional | | $7.68 | $21.94 | $35.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.47 / $33.20 / $45.97
| Professional | | $20.47 | $33.20 | $45.97 |