- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.90 / $15.75 / $20.22
| Facility | | $13.90 | $15.75 | $20.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.61 / $13.61 / $13.61
| Professional | | $13.61 | $13.61 | $13.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $20.22 / $20.22
| Professional | | $13.35 | $20.22 | $20.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.86 / $32.83 / $39.95
| Professional | | $25.86 | $32.83 | $39.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.85 / $20.22 / $25.28
| Professional | | $16.85 | $20.22 | $25.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $20.22 / $32.70
| Professional | | $7.08 | $20.22 | $32.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.32 / $31.02 / $43.55
| Professional | | $14.32 | $31.02 | $43.55 |