- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.94 / $11.93 / $14.46
| Facility | | $9.94 | $11.93 | $14.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.34 / $14.08 / $16.54
| Professional | | $10.34 | $14.08 | $16.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $14.46 / $20.00
| Professional | | $14.46 | $14.46 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.60 / $25.85 / $30.24
| Professional | | $19.60 | $25.85 | $30.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.05 / $14.46 / $18.07
| Professional | | $12.05 | $14.46 | $18.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $14.46 / $18.07
| Professional | | $14.46 | $14.46 | $18.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.05 / $21.72 / $30.31
| Professional | | $12.05 | $21.72 | $30.31 |