- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.67 / $20.03 / $25.70
| Facility | | $17.67 | $20.03 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $14.00 / $14.00
| Professional | | $14.00 | $14.00 | $14.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.07 / $25.70 / $25.70
| Professional | | $17.07 | $25.70 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.95 / $43.60 / $50.81
| Professional | | $36.95 | $43.60 | $50.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.56 / $25.70 / $29.99
| Professional | | $23.56 | $25.70 | $29.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $32.13 / $41.57
| Professional | | $25.70 | $32.13 | $41.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.99 / $38.61 / $53.87
| Professional | | $23.99 | $38.61 | $53.87 |