- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.04 / $12.51 / $16.05
| Facility | | $11.04 | $12.51 | $16.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.60 / $16.05 / $16.05
| Professional | | $10.60 | $16.05 | $16.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.77 / $28.71 / $33.54
| Professional | | $21.77 | $28.71 | $33.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $16.05 / $20.07
| Professional | | $13.38 | $16.05 | $20.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $16.05 / $25.96
| Professional | | $5.62 | $16.05 | $25.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.99 / $24.30 / $33.64
| Professional | | $14.99 | $24.30 | $33.64 |