- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.25 / $11.62 / $14.92
| Facility | | $10.25 | $11.62 | $14.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.02 / $14.92 / $14.92
| Professional | | $9.02 | $14.92 | $14.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.47 / $24.36 / $28.53
| Professional | | $18.47 | $24.36 | $28.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.43 / $14.92 / $18.64
| Professional | | $12.43 | $14.92 | $18.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.22 / $14.92 / $22.04
| Professional | | $5.22 | $14.92 | $22.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.92 / $20.63 / $28.57
| Professional | | $13.92 | $20.63 | $28.57 |