- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.50 / $17.57 / $22.55
| Facility | | $15.50 | $17.57 | $22.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.93 / $16.93 / $20.67
| Professional | | $16.93 | $16.93 | $20.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $22.55 / $22.55
| Professional | | $14.92 | $22.55 | $22.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.58 / $40.34 / $47.15
| Professional | | $30.58 | $40.34 | $47.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.79 / $22.55 / $28.19
| Professional | | $18.79 | $22.55 | $28.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.89 / $22.55 / $36.47
| Professional | | $7.89 | $22.55 | $36.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.04 / $34.14 / $47.27
| Professional | | $21.04 | $34.14 | $47.27 |