- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.90 / $16.89 / $21.67
| Facility | | $14.90 | $16.89 | $21.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.30 / $24.30 / $24.30
| Professional | | $24.30 | $24.30 | $24.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $21.67 / $21.67
| Professional | | $16.48 | $21.67 | $21.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.83 / $44.62 / $52.25
| Professional | | $33.83 | $44.62 | $52.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.05 / $21.67 / $27.09
| Professional | | $18.05 | $21.67 | $27.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.59 / $21.67 / $40.40
| Professional | | $7.59 | $21.67 | $40.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.23 / $37.79 / $52.33
| Professional | | $20.23 | $37.79 | $52.33 |