- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.38 / $12.89 / $16.55
| Facility | | $11.38 | $12.89 | $16.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.82 / $16.55 / $16.55
| Professional | | $9.82 | $16.55 | $16.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.30 / $26.79 / $31.36
| Professional | | $20.30 | $26.79 | $31.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.79 / $16.55 / $20.69
| Professional | | $13.79 | $16.55 | $20.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.79 / $16.55 / $24.25
| Professional | | $5.79 | $16.55 | $24.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.44 / $22.70 / $31.43
| Professional | | $15.44 | $22.70 | $31.43 |