- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.38 / $12.45 / $15.10
| Facility | | $10.38 | $12.45 | $15.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.58 / $13.84 / $15.10
| Professional | | $12.58 | $13.84 | $15.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.01 / $15.10 / $15.10
| Professional | | $10.01 | $15.10 | $15.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.45 / $25.61 / $31.56
| Professional | | $20.45 | $25.61 | $31.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.58 / $15.10 / $18.87
| Professional | | $12.58 | $15.10 | $18.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.10 / $15.10 / $18.87
| Professional | | $15.10 | $15.10 | $18.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.09 / $22.85 / $31.64
| Professional | | $14.09 | $22.85 | $31.64 |