- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.49 / $16.22 / $19.50
| Facility | | $13.49 | $16.22 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $15.14 / $15.14
| Professional | | $5.01 | $15.14 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $12.88 / $19.50
| Professional | | $12.88 | $12.88 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $36.31 / $39.81
| Professional | | $28.18 | $36.31 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $19.50 / $24.55
| Professional | | $16.22 | $19.50 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.92 / $22.91 / $31.62
| Professional | | $6.92 | $22.91 | $31.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.20 / $29.51 / $40.74
| Professional | | $18.20 | $29.51 | $40.74 |