- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.64 / $8.64 / $32.65
| Facility | | $8.64 | $8.64 | $32.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.65 / $32.65 / $32.65
| Facility | | $32.65 | $32.65 | $32.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.32 / $19.32 / $19.32
| Professional | | $19.32 | $19.32 | $19.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.16 / $30.16 / $35.59
| Professional | | $30.16 | $30.16 | $35.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.26 / $23.19 / $27.06
| Professional | | $21.26 | $23.19 | $27.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.32 / $24.79 / $29.00
| Professional | | $19.32 | $24.79 | $29.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.95 / $20.74 / $25.00
| Professional | | $5.95 | $20.74 | $25.00 |