- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.56 / $16.50 / $21.18
| Facility | | $14.56 | $16.50 | $21.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.59 / $15.59 / $15.59
| Professional | | $15.59 | $15.59 | $15.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.74 / $21.18 / $21.18
| Professional | | $13.74 | $21.18 | $21.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $37.17 / $43.46
| Professional | | $28.18 | $37.17 | $43.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.64 / $21.18 / $26.48
| Professional | | $17.64 | $21.18 | $26.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.41 / $21.18 / $33.61
| Professional | | $7.41 | $21.18 | $33.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.77 / $31.46 / $43.56
| Professional | | $19.77 | $31.46 | $43.56 |