- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.33 / $12.84 / $16.48
| Facility | | $11.33 | $12.84 | $16.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $7.28 / $13.73
| Professional | | $7.28 | $7.28 | $13.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $16.48 / $16.48
| Professional | | $10.80 | $16.48 | $16.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $26.72 / $32.53
| Professional | | $21.05 | $26.72 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.73 / $16.48 / $20.60
| Professional | | $13.73 | $16.48 | $20.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.77 / $16.48 / $26.66
| Professional | | $5.77 | $16.48 | $26.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.38 / $25.29 / $34.51
| Professional | | $15.38 | $25.29 | $34.51 |