- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.96 / $11.96 / $11.96
| Facility | | $11.96 | $11.96 | $11.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.22 / $6.22 / $8.21
| Professional | | $6.22 | $6.22 | $8.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.98 / $5.98 / $5.98
| Professional | | $5.98 | $5.98 | $5.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.73 / $8.73 / $8.73
| Professional | | $8.73 | $8.73 | $8.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.58 / $7.17 / $8.36
| Professional | | $6.58 | $7.17 | $8.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.98 / $7.17 / $8.97
| Professional | | $5.98 | $7.17 | $8.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.98 / $7.24 / $7.71
| Professional | | $5.98 | $7.24 | $7.71 |