- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.38 / $18.45 / $22.37
| Facility | | $15.38 | $18.45 | $22.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $13.38 / $25.59
| Professional | | $13.38 | $13.38 | $25.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $22.37 / $22.37
| Professional | | $10.80 | $22.37 | $22.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.28 / $29.40 / $34.34
| Professional | | $22.28 | $29.40 | $34.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.64 / $22.37 / $27.96
| Professional | | $18.64 | $22.37 | $27.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.83 / $22.37 / $27.96
| Professional | | $7.83 | $22.37 | $27.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.81 / $27.40 / $41.94
| Professional | | $20.81 | $27.40 | $41.94 |