- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.63 / $15.45 / $19.82
| Facility | | $13.63 | $15.45 | $19.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.15 / $19.82 / $19.82
| Professional | | $13.15 | $19.82 | $19.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.86 / $35.43 / $41.48
| Professional | | $26.86 | $35.43 | $41.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.52 / $19.82 / $24.78
| Professional | | $16.52 | $19.82 | $24.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.82 / $19.82 / $24.78
| Professional | | $19.82 | $19.82 | $24.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.50 / $30.02 / $41.56
| Professional | | $18.50 | $30.02 | $41.56 |