- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.80 / $8.80 / $8.80
| Facility | | $8.80 | $8.80 | $8.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $9.77 / $12.20
| Professional | | $9.77 | $9.77 | $12.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.07 / $7.07 / $7.07
| Professional | | $7.07 | $7.07 | $7.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.46 / $19.09 / $22.32
| Professional | | $14.46 | $19.09 | $22.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.89 / $10.67 / $13.34
| Professional | | $8.89 | $10.67 | $13.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.73 / $10.67 / $17.26
| Professional | | $3.73 | $10.67 | $17.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.03 / $15.35 / $17.64
| Professional | | $13.03 | $15.35 | $17.64 |