- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.19 / $10.43 / $13.38
| Facility | | $9.19 | $10.43 | $13.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.83 / $13.38 / $13.38
| Professional | | $8.83 | $13.38 | $13.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.14 / $23.93 / $28.03
| Professional | | $18.14 | $23.93 | $28.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.15 / $13.38 / $16.73
| Professional | | $11.15 | $13.38 | $16.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.68 / $13.38 / $21.65
| Professional | | $4.68 | $13.38 | $21.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.49 / $20.25 / $28.04
| Professional | | $12.49 | $20.25 | $28.04 |