- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.42 / $14.07 / $18.05
| Facility | | $12.42 | $14.07 | $18.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $18.05 / $18.05
| Professional | | $11.98 | $18.05 | $18.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.45 / $32.26 / $37.79
| Professional | | $24.45 | $32.26 | $37.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.05 / $18.05 / $22.58
| Professional | | $15.05 | $18.05 | $22.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.32 / $18.05 / $29.23
| Professional | | $6.32 | $18.05 | $29.23 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.05 / $27.13 / $37.85
| Professional | | $15.05 | $27.13 | $37.85 |