- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.40 / $9.52 / $12.22
| Facility | | $8.40 | $9.52 | $12.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.05 / $12.22 / $12.22
| Professional | | $8.05 | $12.22 | $12.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.54 / $21.82 / $25.57
| Professional | | $16.54 | $21.82 | $25.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.18 / $12.22 / $15.27
| Professional | | $10.18 | $12.22 | $15.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.28 / $12.22 / $19.78
| Professional | | $4.28 | $12.22 | $19.78 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.40 / $18.50 / $25.61
| Professional | | $11.40 | $18.50 | $25.61 |