- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.35 / $12.87 / $16.51
| Facility | | $11.35 | $12.87 | $16.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.99 / $16.51 / $16.51
| Professional | | $10.99 | $16.51 | $16.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.38 / $29.53 / $34.54
| Professional | | $22.38 | $29.53 | $34.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.76 / $16.51 / $20.64
| Professional | | $13.76 | $16.51 | $20.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.78 / $16.51 / $26.72
| Professional | | $5.78 | $16.51 | $26.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.41 / $25.00 / $34.61
| Professional | | $15.41 | $25.00 | $34.61 |