- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.86 / $10.03 / $12.89
| Facility | | $8.86 | $10.03 | $12.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.44 / $12.89 / $12.89
| Professional | | $8.44 | $12.89 | $12.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.48 / $21.89 / $26.96
| Professional | | $17.48 | $21.89 | $26.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.74 / $12.89 / $16.11
| Professional | | $10.74 | $12.89 | $16.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.51 / $12.89 / $20.85
| Professional | | $4.51 | $12.89 | $20.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.03 / $19.51 / $27.02
| Professional | | $12.03 | $19.51 | $27.02 |