- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.44 / $28.18 / $33.88
| Facility | | $23.44 | $28.18 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $21.88 / $26.92
| Professional | | $10.96 | $21.88 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $33.88
| Professional | | $15.85 | $15.85 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $48.98
| Professional | | $34.67 | $44.67 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $33.88 / $42.66
| Professional | | $28.18 | $33.88 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $33.88 / $42.66
| Professional | | $12.02 | $33.88 | $42.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $37.15 / $51.29
| Professional | | $29.51 | $37.15 | $51.29 |