- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.55 / $11.48 / $13.80
| Facility | | $9.55 | $11.48 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $7.94 / $10.96
| Professional | | $6.03 | $7.94 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.80 / $13.80 / $13.80
| Professional | | $13.80 | $13.80 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $25.70 / $28.18
| Professional | | $19.95 | $25.70 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $13.80 / $17.38
| Professional | | $11.48 | $13.80 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.79 / $11.48 / $17.38
| Professional | | $4.79 | $11.48 | $17.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $15.49 / $25.70
| Professional | | $9.77 | $15.49 | $25.70 |