- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.55 / $13.09 / $16.80
| Facility | | $11.55 | $13.09 | $16.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.00 / $16.19 / $19.22
| Professional | | $9.00 | $16.19 | $19.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.19 / $16.80 / $16.80
| Professional | | $11.19 | $16.80 | $16.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.76 / $30.02 / $35.14
| Professional | | $22.76 | $30.02 | $35.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $16.80 / $21.00
| Professional | | $14.00 | $16.80 | $21.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.88 / $16.80 / $27.19
| Professional | | $5.88 | $16.80 | $27.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.68 / $25.44 / $35.22
| Professional | | $15.68 | $25.44 | $35.22 |