- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.48 / $13.80 / $16.60
| Facility | | $11.48 | $13.80 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $12.88 / $12.88
| Professional | | $7.94 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $10.96 / $16.60
| Professional | | $10.96 | $10.96 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.99 / $33.88 / $33.88
| Professional | | $23.99 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.80 / $16.60 / $20.89
| Professional | | $13.80 | $16.60 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.89 / $19.50 / $26.92
| Professional | | $5.89 | $19.50 | $26.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.49 / $25.12 / $34.67
| Professional | | $15.49 | $25.12 | $34.67 |