- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.61 / $14.30 / $18.35
| Facility | | $12.61 | $14.30 | $18.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.01 / $18.01 / $18.01
| Professional | | $18.01 | $18.01 | $18.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $18.35 / $18.35
| Professional | | $11.98 | $18.35 | $18.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.09 / $29.32 / $35.69
| Professional | | $23.09 | $29.32 | $35.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.29 / $18.35 / $22.94
| Professional | | $15.29 | $18.35 | $22.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.35 / $18.35 / $22.94
| Professional | | $18.35 | $18.35 | $22.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.00 / $32.00 / $38.90
| Professional | | $13.00 | $32.00 | $38.90 |