- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.50 / $22.10 / $28.37
| Facility | | $19.50 | $22.10 | $28.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.76 / $26.76 / $32.46
| Professional | | $26.76 | $26.76 | $32.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.26 / $28.37 / $28.37
| Professional | | $18.26 | $28.37 | $28.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.65 / $49.66 / $58.07
| Professional | | $37.65 | $49.66 | $58.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.64 / $28.37 / $35.46
| Professional | | $23.64 | $28.37 | $35.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.93 / $28.37 / $44.92
| Professional | | $9.93 | $28.37 | $44.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.48 / $42.03 / $58.19
| Professional | | $26.48 | $42.03 | $58.19 |