- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.80 / $12.24 / $15.71
| Facility | | $10.80 | $12.24 | $15.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.19 / $15.71 / $15.71
| Professional | | $11.19 | $15.71 | $15.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.04 / $30.40 / $35.60
| Professional | | $23.04 | $30.40 | $35.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.09 / $15.71 / $19.64
| Professional | | $13.09 | $15.71 | $19.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $15.71 / $27.52
| Professional | | $5.50 | $15.71 | $27.52 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.66 / $25.75 / $35.65
| Professional | | $14.66 | $25.75 | $35.65 |