- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.25 / $17.10 / $55.15
| Facility | | $14.25 | $17.10 | $55.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.08 / $24.78 / $71.84
| Professional | | $23.08 | $24.78 | $71.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Professional | | $20.72 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.89 / $25.26 / $30.74
| Professional | | $19.89 | $25.26 | $30.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.27 / $20.72 / $25.91
| Professional | | $17.27 | $20.72 | $25.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $20.72 / $25.91
| Professional | | $7.25 | $20.72 | $25.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.68 / $20.38 / $31.09
| Professional | | $14.68 | $20.38 | $31.09 |