- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.13 / $9.77 / $11.75
| Facility | | $8.13 | $9.77 | $11.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $7.08 / $8.91
| Professional | | $6.03 | $7.08 | $8.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $7.08 / $7.08
| Professional | | $7.08 | $7.08 | $7.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.49 / $19.95 / $21.88
| Professional | | $15.49 | $19.95 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $11.75 / $14.79
| Professional | | $9.77 | $11.75 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.89 / $12.59 / $14.79
| Professional | | $5.89 | $12.59 | $14.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.78 / $17.78 / $21.88
| Professional | | $17.78 | $17.78 | $21.88 |