- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.80 / $16.60 / $20.42
| Facility | | $13.80 | $16.60 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $14.13 / $15.85
| Professional | | $10.96 | $14.13 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $11.48 / $20.42
| Professional | | $11.48 | $11.48 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $41.69 / $41.69
| Professional | | $28.84 | $41.69 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $20.42 / $25.12
| Professional | | $16.98 | $20.42 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $20.89 / $25.12
| Professional | | $7.08 | $20.89 | $25.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $24.55 / $38.02
| Professional | | $14.45 | $24.55 | $38.02 |