- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.19 / $14.95 / $19.19
| Facility | | $13.19 | $14.95 | $19.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $19.19 / $19.19
| Professional | | $10.40 | $19.19 | $19.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.44 / $28.28 / $33.09
| Professional | | $21.44 | $28.28 | $33.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.99 / $19.19 / $23.99
| Professional | | $15.99 | $19.19 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.43 / $19.19 / $25.61
| Professional | | $18.43 | $19.19 | $25.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.91 / $23.96 / $34.10
| Professional | | $17.91 | $23.96 | $34.10 |