- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.76 / $9.33 / $11.22
| Facility | | $7.76 | $9.33 | $11.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $7.08 / $8.91
| Professional | | $5.01 | $7.08 | $8.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $5.50 / $11.22
| Professional | | $5.50 | $5.50 | $11.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $15.14 / $16.98
| Professional | | $12.02 | $15.14 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.33 / $11.22 / $14.13
| Professional | | $9.33 | $11.22 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $11.22 / $14.13
| Professional | | $3.98 | $11.22 | $14.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $12.88 / $20.42
| Professional | | $10.00 | $12.88 | $20.42 |