- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.70 / $12.70 / $12.70
| Facility | | $12.70 | $12.70 | $12.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.07 / $9.07 / $9.07
| Professional | | $9.07 | $9.07 | $9.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.90 / $11.90 / $11.90
| Professional | | $11.90 | $11.90 | $11.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.97 / $10.88 / $12.69
| Professional | | $9.97 | $10.88 | $12.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.07 / $9.77 / $13.61
| Professional | | $9.07 | $9.77 | $13.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.12 / $8.92 / $21.08
| Professional | | $7.12 | $8.92 | $21.08 |