- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.04 / $17.05 / $21.88
| Facility | | $15.04 | $17.05 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $21.88 / $21.88
| Professional | | $10.40 | $21.88 | $21.88 |
- 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
- $18.23 / $21.88 / $27.35
| Professional | | $18.23 | $21.88 | $27.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.66 / $21.88 / $27.35
| Professional | | $7.66 | $21.88 | $27.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.35 / $24.61 / $34.10
| Professional | | $19.35 | $24.61 | $34.10 |