- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.70 / $14.39 / $18.47
| Facility | | $12.70 | $14.39 | $18.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $13.72 / $13.72
| Professional | | $13.72 | $13.72 | $13.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.17 / $18.47 / $18.47
| Professional | | $12.17 | $18.47 | $18.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.02 / $33.01 / $38.64
| Professional | | $25.02 | $33.01 | $38.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.39 / $18.47 / $23.09
| Professional | | $15.39 | $18.47 | $23.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $18.47 / $29.87
| Professional | | $6.46 | $18.47 | $29.87 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.23 / $27.95 / $38.70
| Professional | | $17.23 | $27.95 | $38.70 |