- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.02 / $13.62 / $17.48
| Facility | | $12.02 | $13.62 | $17.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.97 / $12.97 / $20.00
| Professional | | $12.97 | $12.97 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $17.48 / $17.48
| Professional | | $11.58 | $17.48 | $17.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.71 / $31.27 / $36.61
| Professional | | $23.71 | $31.27 | $36.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.57 / $17.48 / $21.86
| Professional | | $14.57 | $17.48 | $21.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.12 / $17.48 / $28.29
| Professional | | $6.12 | $17.48 | $28.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.57 / $26.26 / $36.65
| Professional | | $14.57 | $26.26 | $36.65 |