- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.72 / $8.75 / $11.23
| Facility | | $7.72 | $8.75 | $11.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.30 / $11.23 / $11.23
| Professional | | $5.30 | $11.23 | $11.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.79 / $14.24 / $16.63
| Professional | | $10.79 | $14.24 | $16.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.36 / $11.23 / $14.04
| Professional | | $9.36 | $11.23 | $14.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.93 / $11.23 / $14.04
| Professional | | $3.93 | $11.23 | $14.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.72 / $12.41 / $17.13
| Professional | | $9.72 | $12.41 | $17.13 |