- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.30 / $14.79 / $17.78
| Facility | | $12.30 | $14.79 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $12.88 / $14.13
| Professional | | $10.00 | $12.88 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $11.75 / $17.78
| Professional | | $11.75 | $11.75 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $33.11 / $36.31
| Professional | | $25.70 | $33.11 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.79 / $17.78 / $22.39
| Professional | | $14.79 | $17.78 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.17 / $20.89 / $28.84
| Professional | | $6.17 | $20.89 | $28.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $26.92 / $37.15
| Professional | | $16.60 | $26.92 | $37.15 |