- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.05 / $19.32 / $24.80
| Facility | | $17.05 | $19.32 | $24.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.01 / $18.01 / $18.01
| Professional | | $18.01 | $18.01 | $18.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $24.80 / $24.80
| Professional | | $16.48 | $24.80 | $24.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.64 / $44.38 / $51.93
| Professional | | $33.64 | $44.38 | $51.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.67 / $24.80 / $31.01
| Professional | | $20.67 | $24.80 | $31.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.68 / $24.80 / $40.13
| Professional | | $8.68 | $24.80 | $40.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.15 / $37.56 / $52.00
| Professional | | $23.15 | $37.56 | $52.00 |