- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.85 / $12.30 / $15.78
| Facility | | $10.85 | $12.30 | $15.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.09 / $15.78 / $15.78
| Professional | | $6.09 | $15.78 | $15.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.58 / $16.60 / $19.42
| Professional | | $12.58 | $16.60 | $19.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.15 / $15.78 / $19.73
| Professional | | $13.15 | $15.78 | $19.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.52 / $15.78 / $19.73
| Professional | | $5.52 | $15.78 | $19.73 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.34 / $15.52 / $23.01
| Professional | | $11.34 | $15.52 | $23.01 |