- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.51 / $10.23 / $12.59
| Facility | | $8.51 | $10.23 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $7.94 / $10.00
| Professional | | $5.01 | $7.94 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.31 / $6.31 / $12.59
| Professional | | $6.31 | $6.31 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.80 / $17.78 / $19.50
| Professional | | $13.80 | $17.78 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $12.59 / $15.49
| Professional | | $10.47 | $12.59 | $15.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.37 / $12.59 / $15.49
| Professional | | $4.37 | $12.59 | $15.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $14.79 / $20.42
| Professional | | $11.75 | $14.79 | $20.42 |