- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.21 / $13.84 / $17.76
| Facility | | $12.21 | $13.84 | $17.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.78 / $17.76 / $17.76
| Professional | | $11.78 | $17.76 | $17.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.08 / $31.76 / $37.11
| Professional | | $24.08 | $31.76 | $37.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.80 / $17.76 / $22.20
| Professional | | $14.80 | $17.76 | $22.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.22 / $17.76 / $28.73
| Professional | | $6.22 | $17.76 | $28.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.57 / $26.88 / $37.22
| Professional | | $16.57 | $26.88 | $37.22 |