- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.61 / $13.16 / $16.88
| Facility | | $11.61 | $13.16 | $16.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.71 / $16.88 / $16.88
| Professional | | $4.71 | $16.88 | $16.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.52 / $14.24 / $15.77
| Professional | | $12.52 | $14.24 | $15.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.07 / $16.88 / $21.11
| Professional | | $14.07 | $16.88 | $21.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.91 / $16.88 / $21.11
| Professional | | $5.91 | $16.88 | $21.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.21 / $13.14 / $20.68
| Professional | | $9.21 | $13.14 | $20.68 |