- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.80 / $19.05 / $24.44
| Facility | | $16.80 | $19.05 | $24.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.53 / $24.44 / $24.44
| Professional | | $3.53 | $24.44 | $24.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.76 / $11.96 / $21.33
| Professional | | $9.76 | $11.96 | $21.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.37 / $24.44 / $30.56
| Professional | | $20.37 | $24.44 | $30.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.35 / $24.44 / $30.56
| Professional | | $6.35 | $24.44 | $30.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.99 / $11.11 / $29.94
| Professional | | $6.99 | $11.11 | $29.94 |