- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.40 / $7.40 / $7.40
| Facility | | $7.40 | $7.40 | $7.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.41 / $8.41 / $8.41
| Professional | | $8.41 | $8.41 | $8.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.39 / $7.39 / $7.39
| Facility | | $7.39 | $7.39 | $7.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.41 / $8.41 / $8.41
| Professional | | $8.41 | $8.41 | $8.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.65 / $5.65 / $5.65
| Professional | | $5.65 | $5.65 | $5.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.25 / $10.09 / $11.77
| Professional | | $9.25 | $10.09 | $11.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.63 / $8.41 / $12.62
| Professional | | $4.63 | $8.41 | $12.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.70 / $3.82 / $4.99
| Professional | | $0.70 | $3.82 | $4.99 |