- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.45 / $15.24 / $19.55
| Facility | | $13.45 | $15.24 | $19.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.94 / $19.55 / $19.55
| Professional | | $2.94 | $19.55 | $19.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.77 / $9.49 / $17.07
| Professional | | $7.77 | $9.49 | $17.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.30 / $19.55 / $24.45
| Professional | | $16.30 | $19.55 | $24.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.05 / $19.55 / $24.45
| Professional | | $5.05 | $19.55 | $24.45 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.56 / $8.84 / $23.96
| Professional | | $5.56 | $8.84 | $23.96 |