- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.14 / $18.20 / $21.88
| Facility | | $15.14 | $18.20 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $16.98 / $16.98
| Professional | | $12.88 | $16.98 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $14.45 / $21.88
| Professional | | $14.45 | $14.45 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $40.74 / $44.67
| Professional | | $31.62 | $40.74 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $21.88 / $35.48
| Professional | | $18.20 | $21.88 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $25.70 / $35.48
| Professional | | $7.76 | $25.70 | $35.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $33.11 / $45.71
| Professional | | $20.42 | $33.11 | $45.71 |