- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.57 / $15.38 / $19.73
| Facility | | $13.57 | $15.38 | $19.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.96 / $19.73 / $19.73
| Professional | | $12.96 | $19.73 | $19.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.77 / $33.51 / $41.33
| Professional | | $26.77 | $33.51 | $41.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.45 / $19.73 / $24.68
| Professional | | $16.45 | $19.73 | $24.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.91 / $19.73 / $31.93
| Professional | | $6.91 | $19.73 | $31.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.42 / $29.67 / $41.40
| Professional | | $18.42 | $29.67 | $41.40 |