- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.89 / $16.88 / $21.66
| Facility | | $14.89 | $16.88 | $21.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.57 / $9.57 / $18.05
| Professional | | $9.57 | $9.57 | $18.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.55 / $21.66 / $21.66
| Professional | | $13.55 | $21.66 | $21.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.36 / $38.72 / $43.07
| Professional | | $29.36 | $38.72 | $43.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.05 / $21.66 / $27.08
| Professional | | $18.05 | $21.66 | $27.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.58 / $21.66 / $35.04
| Professional | | $7.58 | $21.66 | $35.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.34 / $27.09 / $43.10
| Professional | | $15.34 | $27.09 | $43.10 |