- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.43 / $8.42 / $10.80
| Facility | | $7.43 | $8.42 | $10.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $10.80 / $10.80
| Professional | | $5.50 | $10.80 | $10.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.21 / $14.79 / $17.28
| Professional | | $11.21 | $14.79 | $17.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.00 / $10.80 / $13.50
| Professional | | $9.00 | $10.80 | $13.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.78 / $10.80 / $13.50
| Professional | | $3.78 | $10.80 | $13.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.08 / $12.69 / $17.80
| Professional | | $10.08 | $12.69 | $17.80 |