- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.12 / $13.74 / $17.63
| Facility | | $12.12 | $13.74 | $17.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $17.57 / $20.17
| Professional | | $16.98 | $17.57 | $20.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $17.63 / $17.63
| Professional | | $11.58 | $17.63 | $17.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.89 / $31.52 / $36.86
| Professional | | $23.89 | $31.52 | $36.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.69 / $17.63 / $22.04
| Professional | | $14.69 | $17.63 | $22.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.17 / $17.63 / $28.51
| Professional | | $6.17 | $17.63 | $28.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.45 / $26.68 / $36.94
| Professional | | $16.45 | $26.68 | $36.94 |