- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.95 / $21.48 / $27.56
| Facility | | $18.95 | $21.48 | $27.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.57 / $12.57 / $14.93
| Professional | | $12.57 | $12.57 | $14.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.56 / $27.56 / $27.56
| Professional | | $27.56 | $27.56 | $27.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.44 / $33.56 / $40.84
| Professional | | $26.44 | $33.56 | $40.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.97 / $27.56 / $34.46
| Professional | | $22.97 | $27.56 | $34.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.65 / $27.56 / $34.46
| Professional | | $9.65 | $27.56 | $34.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.52 / $31.01 / $51.68
| Professional | | $19.52 | $31.01 | $51.68 |