- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.55 / $10.83 / $13.90
| Facility | | $9.55 | $10.83 | $13.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $11.58 / $11.58
| Professional | | $11.58 | $11.58 | $11.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $13.90 / $13.90
| Professional | | $9.23 | $13.90 | $13.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.80 / $24.80 / $29.05
| Professional | | $18.80 | $24.80 | $29.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $13.90 / $17.37
| Professional | | $11.58 | $13.90 | $17.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.86 / $13.90 / $22.47
| Professional | | $4.86 | $13.90 | $22.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.97 / $21.02 / $29.11
| Professional | | $12.97 | $21.02 | $29.11 |