- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.29 / $13.93 / $17.88
| Facility | | $12.29 | $13.93 | $17.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.78 / $17.88 / $17.88
| Professional | | $11.78 | $17.88 | $17.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.22 / $31.95 / $37.38
| Professional | | $24.22 | $31.95 | $37.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.90 / $17.88 / $22.35
| Professional | | $14.90 | $17.88 | $22.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.26 / $17.88 / $28.91
| Professional | | $6.26 | $17.88 | $28.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.69 / $27.07 / $37.47
| Professional | | $16.69 | $27.07 | $37.47 |