- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.25 / $16.14 / $20.72
| Facility | | $14.25 | $16.14 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.25 / $20.72 / $20.72
| Professional | | $8.25 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.97 / $22.37 / $26.14
| Professional | | $16.97 | $22.37 | $26.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.27 / $20.72 / $25.91
| Professional | | $17.27 | $20.72 | $25.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $20.72 / $25.91
| Professional | | $7.25 | $20.72 | $25.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.29 / $20.72 / $30.22
| Professional | | $15.29 | $20.72 | $30.22 |