- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.85 / $17.82 / $21.60
| Facility | | $14.85 | $17.82 | $21.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.33 / $21.60 / $21.60
| Professional | | $14.33 | $21.60 | $21.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.26 / $38.60 / $45.19
| Professional | | $29.26 | $38.60 | $45.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.00 / $21.60 / $27.00
| Professional | | $18.00 | $21.60 | $27.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.56 / $21.60 / $34.94
| Professional | | $7.56 | $21.60 | $34.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.16 / $32.70 / $45.27
| Professional | | $20.16 | $32.70 | $45.27 |