- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.67 / $13.22 / $16.97
| Facility | | $11.67 | $13.22 | $16.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.87 / $16.97 / $16.97
| Professional | | $6.87 | $16.97 | $16.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.95 / $18.39 / $21.52
| Professional | | $13.95 | $18.39 | $21.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.14 / $16.97 / $21.21
| Professional | | $14.14 | $16.97 | $21.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.94 / $16.97 / $21.21
| Professional | | $5.94 | $16.97 | $21.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.58 / $17.04 / $24.75
| Professional | | $12.58 | $17.04 | $24.75 |