- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.62 / $22.39 / $30.90
| Facility | | $18.62 | $22.39 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $19.05 / $30.90
| Professional | | $14.13 | $19.05 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $15.85 / $27.54
| Professional | | $14.13 | $15.85 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $48.98
| Professional | | $34.67 | $44.67 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $27.54 / $33.88
| Professional | | $25.12 | $27.54 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $27.54 / $38.90
| Professional | | $14.13 | $27.54 | $38.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $36.31 / $51.29
| Professional | | $25.70 | $36.31 | $51.29 |