- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.14 / $13.75 / $17.64
| Facility | | $12.14 | $13.75 | $17.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.58 / $17.64 / $17.64
| Professional | | $11.58 | $17.64 | $17.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.94 / $31.57 / $36.92
| Professional | | $23.94 | $31.57 | $36.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.71 / $17.64 / $22.07
| Professional | | $14.71 | $17.64 | $22.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.18 / $17.64 / $28.56
| Professional | | $6.18 | $17.64 | $28.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $26.72 / $36.99
| Professional | | $16.48 | $26.72 | $36.99 |