- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.82 / $12.82 / $12.82
| Facility | | $12.82 | $12.82 | $12.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $7.28 / $7.28
| Professional | | $7.28 | $7.28 | $7.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.82 / $12.82 / $12.82
| Facility | | $12.82 | $12.82 | $12.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $7.28 / $7.28
| Professional | | $7.28 | $7.28 | $7.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.32 / $10.32 / $10.32
| Professional | | $10.32 | $10.32 | $10.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.00 / $8.73 / $10.19
| Professional | | $8.00 | $8.73 | $10.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.28 / $8.48 / $10.92
| Professional | | $7.28 | $8.48 | $10.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.02 / $7.03 / $8.55
| Professional | | $6.02 | $7.03 | $8.55 |