- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.40 / $14.05 / $18.04
| Facility | | $12.40 | $14.05 | $18.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.54 / $25.54 / $25.54
| Professional | | $25.54 | $25.54 | $25.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $18.04 / $18.04
| Professional | | $11.98 | $18.04 | $18.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.45 / $32.26 / $37.72
| Professional | | $24.45 | $32.26 | $37.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.03 / $18.04 / $22.55
| Professional | | $15.03 | $18.04 | $22.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.31 / $18.04 / $29.18
| Professional | | $6.31 | $18.04 | $29.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.82 / $27.30 / $37.79
| Professional | | $16.82 | $27.30 | $37.79 |