- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.60 / $19.95 / $24.55
| Facility | | $16.60 | $19.95 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $17.78 / $19.05
| Professional | | $15.14 | $17.78 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $16.22 / $24.55
| Professional | | $16.22 | $16.22 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.11 / $42.66 / $46.77
| Professional | | $33.11 | $42.66 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $24.55 / $30.20
| Professional | | $20.42 | $24.55 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.51 / $28.18 / $37.15
| Professional | | $8.51 | $28.18 | $37.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $34.67 / $47.86
| Professional | | $22.91 | $34.67 | $47.86 |