- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.93 / $12.39 / $15.90
| Facility | | $10.93 | $12.39 | $15.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $13.25 / $13.25
| Professional | | $13.25 | $13.25 | $13.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.82 / $15.90 / $15.90
| Professional | | $9.82 | $15.90 | $15.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.43 / $23.00 / $25.62
| Professional | | $17.43 | $23.00 | $25.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $15.90 / $19.88
| Professional | | $13.25 | $15.90 | $19.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.90 / $15.90 / $25.74
| Professional | | $15.90 | $15.90 | $25.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.26 / $23.34 / $34.36
| Professional | | $11.26 | $23.34 | $34.36 |