- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.26 / $15.03 / $19.28
| Facility | | $13.26 | $15.03 | $19.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.51 / $8.51 / $16.07
| Professional | | $8.51 | $8.51 | $16.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.76 / $19.28 / $19.28
| Professional | | $12.76 | $19.28 | $19.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.11 / $34.43 / $40.29
| Professional | | $26.11 | $34.43 | $40.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.07 / $19.28 / $24.11
| Professional | | $16.07 | $19.28 | $24.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.75 / $19.28 / $31.19
| Professional | | $6.75 | $19.28 | $31.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.00 / $28.95 / $40.39
| Professional | | $18.00 | $28.95 | $40.39 |