- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.52 / $11.92 / $15.30
| Facility | | $10.52 | $11.92 | $15.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $15.30 / $15.30
| Professional | | $9.23 | $15.30 | $15.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.95 / $24.98 / $29.20
| Professional | | $18.95 | $24.98 | $29.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.75 / $15.30 / $19.13
| Professional | | $12.75 | $15.30 | $19.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.36 / $15.30 / $22.59
| Professional | | $5.36 | $15.30 | $22.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.28 / $21.14 / $29.27
| Professional | | $14.28 | $21.14 | $29.27 |