- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.03 / $9.11 / $11.69
| Facility | | $8.03 | $9.11 | $11.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.69 / $11.69 / $11.69
| Professional | | $11.69 | $11.69 | $11.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.35 / $13.59 / $13.59
| Professional | | $12.35 | $13.59 | $13.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.74 / $11.69 / $14.61
| Professional | | $9.74 | $11.69 | $14.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.84 / $11.69 / $14.61
| Professional | | $5.84 | $11.69 | $14.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.74 / $9.74 / $9.74
| Professional | | $9.74 | $9.74 | $9.74 |