- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.05 / $13.65 / $17.52
| Facility | | $12.05 | $13.65 | $17.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.00 / $13.00 / $13.00
| Professional | | $13.00 | $13.00 | $13.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $17.52 / $17.52
| Professional | | $11.58 | $17.52 | $17.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.75 / $31.32 / $36.67
| Professional | | $23.75 | $31.32 | $36.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.60 / $17.52 / $21.90
| Professional | | $14.60 | $17.52 | $21.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.13 / $17.52 / $28.34
| Professional | | $6.13 | $17.52 | $28.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.35 / $26.51 / $36.70
| Professional | | $16.35 | $26.51 | $36.70 |