- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.78 / $21.38 / $25.70
| Facility | | $17.78 | $21.38 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $19.95 / $19.95
| Professional | | $15.14 | $19.95 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $16.98 / $25.70
| Professional | | $16.98 | $16.98 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $47.86 / $52.48
| Professional | | $37.15 | $47.86 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.70 / $32.36
| Professional | | $21.38 | $25.70 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.12 / $30.20 / $41.69
| Professional | | $9.12 | $30.20 | $41.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.99 / $38.90 / $53.70
| Professional | | $23.99 | $38.90 | $53.70 |