- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.55 / $11.48 / $13.80
| Facility | | $9.55 | $11.48 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $8.91 / $10.96
| Professional | | $3.98 | $8.91 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.33 / $9.33 / $13.80
| Professional | | $9.33 | $9.33 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $25.70 / $28.18
| Professional | | $19.95 | $25.70 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $13.80 / $22.39
| Professional | | $11.48 | $13.80 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.79 / $16.22 / $22.39
| Professional | | $4.79 | $16.22 | $22.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $20.89 / $28.84
| Professional | | $11.48 | $20.89 | $28.84 |