- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.22 / $13.49 / $16.22
| Facility | | $11.22 | $13.49 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $12.02 / $12.88
| Professional | | $10.00 | $12.02 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $10.23 / $16.22
| Professional | | $10.23 | $10.23 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.44 / $30.20 / $33.11
| Professional | | $23.44 | $30.20 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $16.22 / $20.42
| Professional | | $13.49 | $16.22 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.75 / $18.62 / $26.30
| Professional | | $5.75 | $18.62 | $26.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $24.55 / $32.36
| Professional | | $15.85 | $24.55 | $32.36 |