- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.14 / $11.49 / $14.75
| Facility | | $10.14 | $11.49 | $14.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.83 / $14.75 / $14.75
| Professional | | $8.83 | $14.75 | $14.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.19 / $23.99 / $28.09
| Professional | | $18.19 | $23.99 | $28.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.29 / $14.75 / $18.44
| Professional | | $12.29 | $14.75 | $18.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.16 / $14.75 / $21.67
| Professional | | $5.16 | $14.75 | $21.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.76 / $20.29 / $28.10
| Professional | | $13.76 | $20.29 | $28.10 |