- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.75 / $11.05 / $14.18
| Facility | | $9.75 | $11.05 | $14.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $14.18 / $14.18
| Professional | | $9.42 | $14.18 | $14.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.22 / $25.36 / $29.65
| Professional | | $19.22 | $25.36 | $29.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.82 / $14.18 / $17.73
| Professional | | $11.82 | $14.18 | $17.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.96 / $14.18 / $22.96
| Professional | | $4.96 | $14.18 | $22.96 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.24 / $21.48 / $29.74
| Professional | | $13.24 | $21.48 | $29.74 |