- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.45 / $11.85 / $15.20
| Facility | | $10.45 | $11.85 | $15.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.01 / $15.20 / $15.20
| Professional | | $10.01 | $15.20 | $15.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.59 / $27.17 / $31.76
| Professional | | $20.59 | $27.17 | $31.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.67 / $15.20 / $19.01
| Professional | | $12.67 | $15.20 | $19.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $15.20 / $24.60
| Professional | | $5.32 | $15.20 | $24.60 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.19 / $23.01 / $31.86
| Professional | | $14.19 | $23.01 | $31.86 |