- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.54 / $18.75 / $24.06
| Facility | | $16.54 | $18.75 | $24.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.51 / $15.51 / $15.51
| Professional | | $15.51 | $15.51 | $15.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.90 / $24.06 / $24.06
| Professional | | $15.90 | $24.06 | $24.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.61 / $40.83 / $47.58
| Professional | | $32.61 | $40.83 | $47.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.06 / $24.06 / $28.07
| Professional | | $22.06 | $24.06 | $28.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.06 / $28.02 / $38.93
| Professional | | $24.06 | $28.02 | $38.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.46 / $36.15 / $50.44
| Professional | | $22.46 | $36.15 | $50.44 |