- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.49 / $33.42 / $42.89
| Facility | | $29.49 | $33.42 | $42.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.20 / $42.89 / $42.89
| Professional | | $21.20 | $42.89 | $42.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.96 / $38.78 / $45.44
| Professional | | $32.96 | $38.78 | $45.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.74 / $42.89 / $53.61
| Professional | | $35.74 | $42.89 | $53.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.01 / $42.89 / $53.61
| Professional | | $15.01 | $42.89 | $53.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.81 / $40.03 / $60.39
| Professional | | $27.81 | $40.03 | $60.39 |