- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.11 / $11.45 / $14.70
| Facility | | $10.11 | $11.45 | $14.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.49 / $6.49 / $12.25
| Professional | | $6.49 | $6.49 | $12.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.82 / $14.70 / $14.70
| Professional | | $9.82 | $14.70 | $14.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.94 / $26.30 / $30.79
| Professional | | $19.94 | $26.30 | $30.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.25 / $14.70 / $18.38
| Professional | | $12.25 | $14.70 | $18.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.15 / $14.70 / $23.78
| Professional | | $5.15 | $14.70 | $23.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $22.27 / $30.83
| Professional | | $13.72 | $22.27 | $30.83 |