- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.92 / $10.11 / $12.97
| Facility | | $8.92 | $10.11 | $12.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.64 / $12.97 / $12.97
| Professional | | $8.64 | $12.97 | $12.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.57 / $23.19 / $27.16
| Professional | | $17.57 | $23.19 | $27.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.81 / $12.97 / $16.22
| Professional | | $10.81 | $12.97 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.54 / $12.97 / $20.99
| Professional | | $4.54 | $12.97 | $20.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.11 / $19.64 / $27.20
| Professional | | $12.11 | $19.64 | $27.20 |