- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.20 / $21.88 / $26.30
| Facility | | $18.20 | $21.88 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $19.95 / $20.89
| Professional | | $15.85 | $19.95 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.38 / $17.38 / $26.30
| Professional | | $17.38 | $17.38 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $48.98 / $53.70
| Professional | | $38.02 | $48.98 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $26.30 / $33.11
| Professional | | $21.88 | $26.30 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.33 / $30.90 / $42.66
| Professional | | $9.33 | $30.90 | $42.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $39.81 / $54.95
| Professional | | $24.55 | $39.81 | $54.95 |