- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.94 / $11.27 / $14.46
| Facility | | $9.94 | $11.27 | $14.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $14.46 / $14.46
| Professional | | $14.46 | $14.46 | $14.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.51 / $23.50 / $28.60
| Professional | | $18.51 | $23.50 | $28.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.05 / $14.46 / $18.07
| Professional | | $12.05 | $14.46 | $18.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.05 / $14.46 / $18.07
| Professional | | $5.05 | $14.46 | $18.07 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.24 / $16.27 / $27.11
| Professional | | $10.24 | $16.27 | $27.11 |