- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.11 / $11.45 / $14.70
| Facility | | $10.11 | $11.45 | $14.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.61 / $14.70 / $14.70
| Professional | | $9.61 | $14.70 | $14.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.94 / $26.30 / $30.72
| Professional | | $19.94 | $26.30 | $30.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.25 / $14.70 / $18.38
| Professional | | $12.25 | $14.70 | $18.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.15 / $14.70 / $23.77
| Professional | | $5.15 | $14.70 | $23.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $22.24 / $30.80
| Professional | | $13.72 | $22.24 | $30.80 |