- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.60 / $15.42 / $19.79
| Facility | | $13.60 | $15.42 | $19.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.99 / $19.79 / $19.79
| Professional | | $10.99 | $19.79 | $19.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.53 / $29.71 / $34.82
| Professional | | $22.53 | $29.71 | $34.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $19.79 / $24.74
| Professional | | $16.48 | $19.79 | $24.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.37 / $19.79 / $24.74
| Professional | | $19.37 | $19.79 | $24.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.47 / $24.99 / $35.83
| Professional | | $18.47 | $24.99 | $35.83 |