- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.80 / $16.60 / $20.42
| Facility | | $13.80 | $16.60 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $14.13 / $16.98
| Professional | | $3.98 | $14.13 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $11.48 / $20.42
| Professional | | $11.48 | $11.48 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $32.36 / $35.48
| Professional | | $25.12 | $32.36 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $20.42 / $25.12
| Professional | | $16.98 | $20.42 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $20.42 / $28.18
| Professional | | $7.08 | $20.42 | $28.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $26.30 / $37.15
| Professional | | $19.05 | $26.30 | $37.15 |