- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.50 / $23.44 / $28.18
| Facility | | $19.50 | $23.44 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $18.20 / $21.88
| Professional | | $14.13 | $18.20 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $28.18
| Professional | | $15.85 | $15.85 | $28.18 |
- 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
- $23.44 / $28.18 / $35.48
| Professional | | $23.44 | $28.18 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $28.18 / $35.48
| Professional | | $10.00 | $28.18 | $35.48 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.44 / $33.88 / $46.77
| Professional | | $23.44 | $33.88 | $46.77 |