- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.19 / $9.27 / $11.92
| Facility | | $8.19 | $9.27 | $11.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.09 / $11.92 / $11.92
| Professional | | $6.09 | $11.92 | $11.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.39 / $16.35 / $19.05
| Professional | | $12.39 | $16.35 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.93 / $11.92 / $14.90
| Professional | | $9.93 | $11.92 | $14.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.17 / $11.92 / $14.90
| Professional | | $4.17 | $11.92 | $14.90 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.12 / $14.00 / $19.67
| Professional | | $11.12 | $14.00 | $19.67 |