- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.59 / $10.87 / $13.96
| Facility | | $9.59 | $10.87 | $13.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.23 / $13.96 / $13.96
| Professional | | $9.23 | $13.96 | $13.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.95 / $24.98 / $29.20
| Professional | | $18.95 | $24.98 | $29.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.63 / $13.96 / $17.45
| Professional | | $11.63 | $13.96 | $17.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.88 / $13.96 / $22.59
| Professional | | $4.88 | $13.96 | $22.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.03 / $21.14 / $29.27
| Professional | | $13.03 | $21.14 | $29.27 |