- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.22 / $12.72 / $16.32
| Facility | | $11.22 | $12.72 | $16.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $16.32 / $16.32
| Professional | | $10.80 | $16.32 | $16.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.10 / $29.15 / $34.17
| Professional | | $22.10 | $29.15 | $34.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.60 / $16.32 / $20.39
| Professional | | $13.60 | $16.32 | $20.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.71 / $16.32 / $26.39
| Professional | | $5.71 | $16.32 | $26.39 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.23 / $24.70 / $34.20
| Professional | | $15.23 | $24.70 | $34.20 |