- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.16 / $11.52 / $14.78
| Facility | | $10.16 | $11.52 | $14.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $14.40 / $14.40
| Professional | | $14.40 | $14.40 | $14.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.82 / $14.78 / $14.78
| Professional | | $9.82 | $14.78 | $14.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.03 / $26.42 / $30.89
| Professional | | $20.03 | $26.42 | $30.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.32 / $14.78 / $18.48
| Professional | | $12.32 | $14.78 | $18.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.17 / $14.78 / $23.91
| Professional | | $5.17 | $14.78 | $23.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.80 / $22.39 / $31.00
| Professional | | $13.80 | $22.39 | $31.00 |