- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.95 / $13.54 / $17.38
| Facility | | $11.95 | $13.54 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.64 / $17.38 / $17.38
| Professional | | $8.64 | $17.38 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.67 / $23.31 / $27.26
| Professional | | $17.67 | $23.31 | $27.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.48 / $17.38 / $21.72
| Professional | | $14.48 | $17.38 | $21.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.08 / $17.38 / $21.72
| Professional | | $6.08 | $17.38 | $21.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.93 / $19.98 / $28.06
| Professional | | $15.93 | $19.98 | $28.06 |