- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $12.59 / $17.38
| Facility | | $10.47 | $12.59 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.91 / $12.02 / $15.14
| Professional | | $8.91 | $12.02 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $15.14
| Professional | | $10.00 | $10.00 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $28.18 / $30.90
| Professional | | $21.88 | $28.18 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $15.14 / $24.55
| Professional | | $12.59 | $15.14 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $17.38 / $24.55
| Professional | | $5.25 | $17.38 | $24.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $22.91 / $31.62
| Professional | | $14.13 | $22.91 | $31.62 |