- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.55 / $14.22 / $18.25
| Facility | | $12.55 | $14.22 | $18.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.98 / $18.25 / $18.25
| Professional | | $11.98 | $18.25 | $18.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.74 / $32.63 / $38.18
| Professional | | $24.74 | $32.63 | $38.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.21 / $18.25 / $22.82
| Professional | | $15.21 | $18.25 | $22.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.39 / $18.25 / $29.53
| Professional | | $6.39 | $18.25 | $29.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.04 / $27.63 / $38.25
| Professional | | $17.04 | $27.63 | $38.25 |