- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.49 / $17.55 / $22.52
| Facility | | $15.49 | $17.55 | $22.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.60 / $22.52 / $22.52
| Professional | | $10.60 | $22.52 | $22.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.63 / $27.08 / $33.43
| Professional | | $21.63 | $27.08 | $33.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.77 / $22.52 / $28.16
| Professional | | $18.77 | $22.52 | $28.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.88 / $22.52 / $28.16
| Professional | | $7.88 | $22.52 | $28.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.53 / $24.92 / $34.40
| Professional | | $19.53 | $24.92 | $34.40 |