- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.14 / $18.14 / $18.14
| Facility | | $18.14 | $18.14 | $18.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.14 / $10.14 / $10.14
| Professional | | $10.14 | $10.14 | $10.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.13 / $18.13 / $18.13
| Facility | | $18.13 | $18.13 | $18.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.14 / $10.14 / $10.14
| Professional | | $10.14 | $10.14 | $10.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.28 / $14.28 / $14.28
| Professional | | $14.28 | $14.28 | $14.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.15 / $12.17 / $14.20
| Professional | | $11.15 | $12.17 | $14.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.14 / $11.73 / $15.21
| Professional | | $10.14 | $11.73 | $15.21 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.93 / $9.49 / $11.83
| Professional | | $7.93 | $9.49 | $11.83 |