- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.05 / $12.52 / $16.07
| Facility | | $11.05 | $12.52 | $16.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.50 / $15.50 / $18.38
| Professional | | $15.50 | $15.50 | $18.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.60 / $16.07 / $16.07
| Professional | | $10.60 | $16.07 | $16.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.77 / $28.71 / $33.61
| Professional | | $21.77 | $28.71 | $33.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.39 / $16.07 / $20.09
| Professional | | $13.39 | $16.07 | $20.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $16.07 / $26.01
| Professional | | $5.62 | $16.07 | $26.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $24.32 / $33.68
| Professional | | $15.00 | $24.32 | $33.68 |