- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.78 / $21.38 / $48.98
| Facility | | $17.78 | $21.38 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $19.50 / $20.89
| Professional | | $15.85 | $19.50 | $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
- $21.88 / $26.92 / $30.20
| Professional | | $21.88 | $26.92 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $26.30 / $32.36
| Professional | | $21.88 | $26.30 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.12 / $26.30 / $32.36
| Professional | | $9.12 | $26.30 | $32.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $21.88 / $33.88
| Professional | | $14.45 | $21.88 | $33.88 |