- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.40 / $10.40 / $12.60
| Facility | | $10.40 | $10.40 | $12.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.64 / $11.41 / $19.50
| Professional | | $8.64 | $11.41 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.66 / $7.66 / $7.66
| Professional | | $7.66 | $7.66 | $7.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.51 / $19.41 / $23.97
| Professional | | $15.51 | $19.41 | $23.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $12.60 / $15.00
| Professional | | $10.50 | $12.60 | $15.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.41 / $12.60 / $18.53
| Professional | | $4.41 | $12.60 | $18.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $14.66 / $18.96
| Professional | | $10.50 | $14.66 | $18.96 |