- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.93 / $12.39 / $15.90
| Facility | | $10.93 | $12.39 | $15.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.60 / $15.90 / $15.90
| Professional | | $10.60 | $15.90 | $15.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.43 / $23.00 / $33.29
| Professional | | $17.43 | $23.00 | $33.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $15.90 / $19.88
| Professional | | $13.25 | $15.90 | $19.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.57 / $15.90 / $25.74
| Professional | | $5.57 | $15.90 | $25.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.84 / $24.08 / $33.34
| Professional | | $14.84 | $24.08 | $33.34 |