- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.44 / $14.10 / $18.10
| Facility | | $12.44 | $14.10 | $18.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.99 / $7.99 / $15.08
| Professional | | $7.99 | $7.99 | $15.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $18.10 / $18.10
| Professional | | $11.98 | $18.10 | $18.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.51 / $32.32 / $37.85
| Professional | | $24.51 | $32.32 | $37.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.08 / $18.10 / $22.62
| Professional | | $15.08 | $18.10 | $22.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.33 / $18.10 / $29.27
| Professional | | $6.33 | $18.10 | $29.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.89 / $27.38 / $37.90
| Professional | | $16.89 | $27.38 | $37.90 |