- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.75 / $14.13 / $19.50
| Facility | | $11.75 | $14.13 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $12.88 / $12.88
| Professional | | $10.00 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $11.48 / $17.38
| Professional | | $11.48 | $11.48 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $31.62 / $35.48
| Professional | | $25.12 | $31.62 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $17.38 / $21.38
| Professional | | $14.45 | $17.38 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $19.95 / $28.18
| Professional | | $6.03 | $19.95 | $28.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $25.70 / $36.31
| Professional | | $16.22 | $25.70 | $36.31 |