- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.24 / $10.47 / $13.44
| Facility | | $9.24 | $10.47 | $13.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.83 / $13.44 / $13.44
| Professional | | $8.83 | $13.44 | $13.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.19 / $23.99 / $28.09
| Professional | | $18.19 | $23.99 | $28.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.20 / $13.44 / $16.80
| Professional | | $11.20 | $13.44 | $16.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.70 / $13.44 / $21.73
| Professional | | $4.70 | $13.44 | $21.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.54 / $20.32 / $28.15
| Professional | | $12.54 | $20.32 | $28.15 |