- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.01 / $12.47 / $16.01
| Facility | | $11.01 | $12.47 | $16.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $16.01 / $16.01
| Professional | | $4.12 | $16.01 | $16.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.13 / $13.02 / $13.97
| Professional | | $11.13 | $13.02 | $13.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.34 / $16.01 / $20.01
| Professional | | $13.34 | $16.01 | $20.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.60 / $16.01 / $20.01
| Professional | | $5.60 | $16.01 | $20.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.95 / $11.35 / $19.61
| Professional | | $7.95 | $11.35 | $19.61 |