- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.80 / $9.98 / $12.80
| Facility | | $8.80 | $9.98 | $12.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.44 / $12.80 / $12.80
| Professional | | $8.44 | $12.80 | $12.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.34 / $22.87 / $26.81
| Professional | | $17.34 | $22.87 | $26.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.67 / $12.80 / $16.01
| Professional | | $10.67 | $12.80 | $16.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.48 / $12.80 / $20.72
| Professional | | $4.48 | $12.80 | $20.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.07 / $15.68 / $26.09
| Professional | | $9.07 | $15.68 | $26.09 |