- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.68 / $13.24 / $16.98
| Facility | | $11.68 | $13.24 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.25 / $16.98 / $16.98
| Professional | | $8.25 | $16.98 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.92 / $22.32 / $26.09
| Professional | | $16.92 | $22.32 | $26.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.16 / $16.98 / $21.24
| Professional | | $14.16 | $16.98 | $21.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.95 / $16.98 / $21.24
| Professional | | $5.95 | $16.98 | $21.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.26 / $19.14 / $26.88
| Professional | | $15.26 | $19.14 | $26.88 |