- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.50 / $8.50 / $10.91
| Facility | | $7.50 | $8.50 | $10.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.00 / $9.69 / $12.48
| Professional | | $9.00 | $9.69 | $12.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.67 / $10.91 / $10.91
| Professional | | $6.67 | $10.91 | $10.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.62 / $17.97 / $21.06
| Professional | | $13.62 | $17.97 | $21.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.09 / $10.91 / $13.64
| Professional | | $9.09 | $10.91 | $13.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.82 / $10.91 / $16.29
| Professional | | $3.82 | $10.91 | $16.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.18 / $15.24 / $21.10
| Professional | | $10.18 | $15.24 | $21.10 |