- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.87 / $13.45 / $17.27
| Facility | | $11.87 | $13.45 | $17.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.10 / $12.10 / $12.10
| Professional | | $12.10 | $12.10 | $12.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.39 / $17.27 / $17.27
| Professional | | $11.39 | $17.27 | $17.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.12 / $28.08 / $34.18
| Professional | | $22.12 | $28.08 | $34.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.39 / $17.27 / $21.59
| Professional | | $14.39 | $17.27 | $21.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.04 / $17.27 / $27.94
| Professional | | $6.04 | $17.27 | $27.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.23 / $26.51 / $37.20
| Professional | | $12.23 | $26.51 | $37.20 |