- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Facility | | $20.72 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $7.54 / $9.94
| Professional | | $7.25 | $7.54 | $9.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Facility | | $20.72 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $7.25 / $7.25
| Professional | | $7.25 | $7.25 | $7.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.03 / $18.03 / $18.03
| Professional | | $18.03 | $18.03 | $18.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.97 / $8.69 / $10.15
| Professional | | $7.97 | $8.69 | $10.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.25 / $9.52 / $10.88
| Professional | | $7.25 | $9.52 | $10.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.51 / $9.61 / $13.94
| Professional | | $7.51 | $9.61 | $13.94 |