- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.95 / $15.81 / $20.29
| Facility | | $13.95 | $15.81 | $20.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.29 / $20.29
| Professional | | $13.35 | $20.29 | $20.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.47 / $36.24 / $42.38
| Professional | | $27.47 | $36.24 | $42.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.91 / $20.29 / $25.37
| Professional | | $16.91 | $20.29 | $25.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.10 / $20.29 / $32.83
| Professional | | $7.10 | $20.29 | $32.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.94 / $30.71 / $42.52
| Professional | | $18.94 | $30.71 | $42.52 |