- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.28 / $10.53 / $13.51
| Facility | | $9.28 | $10.53 | $13.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.83 / $13.51 / $13.51
| Professional | | $8.83 | $13.51 | $13.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.30 / $21.98 / $26.75
| Professional | | $17.30 | $21.98 | $26.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.26 / $13.51 / $16.89
| Professional | | $11.26 | $13.51 | $16.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.73 / $13.51 / $21.85
| Professional | | $4.73 | $13.51 | $21.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.57 / $18.07 / $27.53
| Professional | | $9.57 | $18.07 | $27.53 |