- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.02 / $14.75 / $18.94
| Facility | | $13.02 | $14.75 | $18.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $18.94 / $18.94
| Professional | | $11.58 | $18.94 | $18.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $31.20 / $36.51
| Professional | | $23.65 | $31.20 | $36.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.78 / $18.94 / $23.67
| Professional | | $15.78 | $18.94 | $23.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.63 / $18.94 / $28.27
| Professional | | $6.63 | $18.94 | $28.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.67 / $26.44 / $36.61
| Professional | | $17.67 | $26.44 | $36.61 |