- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.94 / $9.00 / $11.56
| Facility | | $7.94 | $9.00 | $11.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.66 / $11.56 / $11.56
| Professional | | $7.66 | $11.56 | $11.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.64 / $20.63 / $24.16
| Professional | | $15.64 | $20.63 | $24.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.63 / $11.56 / $14.45
| Professional | | $9.63 | $11.56 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.04 / $11.56 / $18.68
| Professional | | $4.04 | $11.56 | $18.68 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.79 / $17.48 / $24.21
| Professional | | $10.79 | $17.48 | $24.21 |