- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.77 / $11.07 / $14.21
| Facility | | $9.77 | $11.07 | $14.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $14.21 / $14.21
| Professional | | $9.42 | $14.21 | $14.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.98 / $25.05 / $29.26
| Professional | | $18.98 | $25.05 | $29.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.84 / $14.21 / $17.76
| Professional | | $11.84 | $14.21 | $17.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.97 / $14.21 / $22.66
| Professional | | $4.97 | $14.21 | $22.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.26 / $21.03 / $29.34
| Professional | | $13.26 | $21.03 | $29.34 |