- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.82 / $12.27 / $15.74
| Facility | | $10.82 | $12.27 | $15.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $15.74 / $15.74
| Professional | | $10.40 | $15.74 | $15.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.35 / $28.16 / $32.99
| Professional | | $21.35 | $28.16 | $32.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.12 / $15.74 / $19.68
| Professional | | $13.12 | $15.74 | $19.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.51 / $15.74 / $25.46
| Professional | | $5.51 | $15.74 | $25.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.69 / $23.83 / $32.99
| Professional | | $14.69 | $23.83 | $32.99 |