- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.90 / $15.75 / $20.22
| Facility | | $13.90 | $15.75 | $20.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.68 / $16.85 / $19.47
| Professional | | $14.68 | $16.85 | $19.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.22 / $20.22
| Professional | | $13.35 | $20.22 | $20.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.38 / $36.11 / $42.27
| Professional | | $27.38 | $36.11 | $42.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.85 / $20.22 / $23.63
| Professional | | $16.85 | $20.22 | $23.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $20.22 / $32.70
| Professional | | $7.08 | $20.22 | $32.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.87 / $30.60 / $42.37
| Professional | | $18.87 | $30.60 | $42.37 |