- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.71 / $17.80 / $22.85
| Facility | | $15.71 | $17.80 | $22.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.02 / $26.14 / $131.00
| Professional | | $22.02 | $26.14 | $131.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.12 / $22.85 / $22.85
| Professional | | $15.12 | $22.85 | $22.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.96 / $40.84 / $47.85
| Professional | | $30.96 | $40.84 | $47.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.04 / $22.85 / $28.56
| Professional | | $19.04 | $22.85 | $28.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.00 / $22.85 / $36.96
| Professional | | $8.00 | $22.85 | $36.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.32 / $34.58 / $47.88
| Professional | | $21.32 | $34.58 | $47.88 |