- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.84 / $13.42 / $17.22
| Facility | | $11.84 | $13.42 | $17.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.39 / $17.22 / $17.22
| Professional | | $11.39 | $17.22 | $17.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.33 / $30.77 / $36.00
| Professional | | $23.33 | $30.77 | $36.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.35 / $17.22 / $21.53
| Professional | | $14.35 | $17.22 | $21.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $17.22 / $27.84
| Professional | | $6.03 | $17.22 | $27.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.07 / $26.07 / $36.09
| Professional | | $16.07 | $26.07 | $36.09 |