- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.83 / $11.15 / $14.30
| Facility | | $9.83 | $11.15 | $14.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $14.30 / $14.30
| Professional | | $9.42 | $14.30 | $14.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.41 / $25.61 / $29.92
| Professional | | $19.41 | $25.61 | $29.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.92 / $14.30 / $17.88
| Professional | | $11.92 | $14.30 | $17.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $14.30 / $23.14
| Professional | | $5.01 | $14.30 | $23.14 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.35 / $21.49 / $29.99
| Professional | | $13.35 | $21.49 | $29.99 |