- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.98 / $17.16 / $17.16
| Facility | | $11.98 | $17.16 | $17.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.68 / $16.32 / $21.54
| Professional | | $15.68 | $16.32 | $21.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.99 / $11.99 / $11.99
| Facility | | $11.99 | $11.99 | $11.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.69 / $15.69 / $15.69
| Professional | | $15.69 | $15.69 | $15.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.16 / $10.16 / $10.16
| Professional | | $10.16 | $10.16 | $10.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.26 / $18.82 / $21.97
| Professional | | $17.26 | $18.82 | $21.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.35 / $15.69 / $23.54
| Professional | | $8.35 | $15.69 | $23.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.39 / $8.15 / $12.37
| Professional | | $2.39 | $8.15 | $12.37 |