- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.75 / $14.45 / $18.54
| Facility | | $12.75 | $14.45 | $18.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.39 / $18.54 / $18.54
| Professional | | $11.39 | $18.54 | $18.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.18 / $29.03 / $35.79
| Professional | | $23.18 | $29.03 | $35.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.45 / $18.54 / $23.18
| Professional | | $15.45 | $18.54 | $23.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.54 / $18.54 / $23.18
| Professional | | $18.54 | $18.54 | $23.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.30 / $25.88 / $35.84
| Professional | | $17.30 | $25.88 | $35.84 |