- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.75 / $14.13 / $16.98
| Facility | | $11.75 | $14.13 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $12.30 / $12.88
| Professional | | $10.00 | $12.30 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.22 / $11.22 / $16.98
| Professional | | $11.22 | $11.22 | $16.98 |
- 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
- $14.13 / $16.98 / $21.38
| Professional | | $14.13 | $16.98 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $19.95 / $27.54
| Professional | | $6.03 | $19.95 | $27.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $25.70 / $35.48
| Professional | | $15.85 | $25.70 | $35.48 |