- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.89 / $16.88 / $21.66
| Facility | | $14.89 | $16.88 | $21.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.05 / $18.05 / $19.01
| Professional | | $18.05 | $18.05 | $19.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.66 / $21.66 / $21.66
| Professional | | $21.66 | $21.66 | $21.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.35 / $24.59 / $32.49
| Professional | | $22.35 | $24.59 | $32.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.05 / $21.66 / $27.08
| Professional | | $18.05 | $21.66 | $27.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.58 / $21.66 / $30.88
| Professional | | $7.58 | $21.66 | $30.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.44 / $24.44 / $27.78
| Professional | | $24.44 | $24.44 | $27.78 |