- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.11 / $20.11 / $20.11
| Facility | | $20.11 | $20.11 | $20.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.14 / $13.57 / $17.60
| Professional | | $13.14 | $13.57 | $17.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $11.98 / $11.98
| Professional | | $11.98 | $11.98 | $11.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.51 / $32.32 / $37.85
| Professional | | $24.51 | $32.32 | $37.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.76 / $20.11 / $25.14
| Professional | | $16.76 | $20.11 | $25.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.06 / $20.11 / $29.27
| Professional | | $10.06 | $20.11 | $29.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.11 / $26.04 / $29.95
| Professional | | $22.11 | $26.04 | $29.95 |