- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.32 / $12.83 / $16.46
| Facility | | $11.32 | $12.83 | $16.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.26 / $7.26 / $13.72
| Professional | | $7.26 | $7.26 | $13.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $16.46 / $16.46
| Professional | | $10.80 | $16.46 | $16.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.28 / $29.40 / $34.39
| Professional | | $22.28 | $29.40 | $34.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $16.46 / $20.58
| Professional | | $13.72 | $16.46 | $20.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.76 / $16.46 / $26.63
| Professional | | $5.76 | $16.46 | $26.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.37 / $24.90 / $34.47
| Professional | | $15.37 | $24.90 | $34.47 |