- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.79 / $15.62 / $20.05
| Facility | | $13.79 | $15.62 | $20.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.15 / $15.15 / $15.15
| Professional | | $15.15 | $15.15 | $15.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.05 / $20.05
| Professional | | $13.35 | $20.05 | $20.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.19 / $35.86 / $41.92
| Professional | | $27.19 | $35.86 | $41.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.71 / $20.05 / $25.07
| Professional | | $16.71 | $20.05 | $25.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.02 / $20.05 / $32.43
| Professional | | $7.02 | $20.05 | $32.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.72 / $30.36 / $42.03
| Professional | | $18.72 | $30.36 | $42.03 |