- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.87 / $14.59 / $18.72
| Facility | | $12.87 | $14.59 | $18.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $18.72 / $18.72
| Professional | | $9.42 | $18.72 | $18.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.51 / $25.73 / $30.11
| Professional | | $19.51 | $25.73 | $30.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.60 / $18.72 / $23.40
| Professional | | $15.60 | $18.72 | $23.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.55 / $18.72 / $23.40
| Professional | | $6.55 | $18.72 | $23.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.47 / $21.79 / $31.01
| Professional | | $17.47 | $21.79 | $31.01 |