- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.93 / $21.45 / $27.53
| Facility | | $18.93 | $21.45 | $27.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.26 / $27.53 / $27.53
| Professional | | $18.26 | $27.53 | $27.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.32 / $49.22 / $57.59
| Professional | | $37.32 | $49.22 | $57.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.94 / $27.53 / $34.40
| Professional | | $22.94 | $27.53 | $34.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.63 / $27.53 / $44.53
| Professional | | $9.63 | $27.53 | $44.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.69 / $41.68 / $57.71
| Professional | | $25.69 | $41.68 | $57.71 |