- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.18 / $15.85 / $19.05
| Facility | | $13.18 | $15.85 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $12.02 / $15.14
| Professional | | $3.98 | $12.02 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $19.05
| Professional | | $10.47 | $10.47 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $29.51 / $32.36
| Professional | | $22.91 | $29.51 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $19.05 / $23.99
| Professional | | $15.85 | $19.05 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.76 / $19.05 / $25.70
| Professional | | $6.76 | $19.05 | $25.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.78 / $23.99 / $33.88
| Professional | | $17.78 | $23.99 | $33.88 |