- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.61 / $8.61 / $11.06
| Facility | | $7.61 | $8.61 | $11.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.26 / $11.06 / $11.06
| Professional | | $7.26 | $11.06 | $11.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.99 / $19.76 / $23.18
| Professional | | $14.99 | $19.76 | $23.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.22 / $11.06 / $13.83
| Professional | | $9.22 | $11.06 | $13.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.87 / $11.06 / $17.91
| Professional | | $3.87 | $11.06 | $17.91 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.33 / $16.76 / $23.20
| Professional | | $10.33 | $16.76 | $23.20 |