- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.88 / $12.33 / $15.83
| Facility | | $10.88 | $12.33 | $15.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.40 / $15.83 / $15.83
| Professional | | $10.40 | $15.83 | $15.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.44 / $28.28 / $33.09
| Professional | | $21.44 | $28.28 | $33.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.19 / $15.83 / $19.79
| Professional | | $13.19 | $15.83 | $19.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.54 / $15.83 / $25.61
| Professional | | $5.54 | $15.83 | $25.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.77 / $23.96 / $33.17
| Professional | | $14.77 | $23.96 | $33.17 |