- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.77 / $9.94 / $12.77
| Facility | | $8.77 | $9.94 | $12.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.44 / $12.77 / $12.77
| Professional | | $8.44 | $12.77 | $12.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.29 / $22.81 / $26.69
| Professional | | $17.29 | $22.81 | $26.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.64 / $12.77 / $15.96
| Professional | | $10.64 | $12.77 | $15.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.47 / $12.77 / $20.65
| Professional | | $4.47 | $12.77 | $20.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.92 / $19.32 / $26.77
| Professional | | $11.92 | $19.32 | $26.77 |