- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.07 / $12.55 / $16.10
| Facility | | $11.07 | $12.55 | $16.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.42 / $16.10 / $16.10
| Professional | | $9.42 | $16.10 | $16.10 |
- 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
- $13.42 / $16.10 / $20.13
| Professional | | $13.42 | $16.10 | $20.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.64 / $16.10 / $23.27
| Professional | | $5.64 | $16.10 | $23.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.03 / $21.79 / $30.20
| Professional | | $15.03 | $21.79 | $30.20 |