- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.65 / $13.65 / $15.47
| Facility | | $13.65 | $13.65 | $15.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.74 / $21.85 / $63.80
| Professional | | $10.74 | $21.85 | $63.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $9.42 / $9.42
| Professional | | $9.42 | $9.42 | $9.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.51 / $25.73 / $30.11
| Professional | | $19.51 | $25.73 | $30.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.55 / $19.86 / $23.17
| Professional | | $16.55 | $19.86 | $23.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $19.86 / $24.83
| Professional | | $14.00 | $19.86 | $24.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.60 / $18.44 / $22.46
| Professional | | $17.60 | $18.44 | $22.46 |