- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.88 / $15.49 / $18.62
| Facility | | $12.88 | $15.49 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $12.88 / $15.14
| Professional | | $10.00 | $12.88 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.22 / $11.22 / $18.62
| Professional | | $11.22 | $11.22 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $31.62 / $34.67
| Professional | | $24.55 | $31.62 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.49 / $18.62 / $23.44
| Professional | | $15.49 | $18.62 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $19.95 / $27.54
| Professional | | $6.46 | $19.95 | $27.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.38 / $25.70 / $35.48
| Professional | | $17.38 | $25.70 | $35.48 |