- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.14 / $8.14 / $8.14
| Facility | | $8.14 | $8.14 | $8.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.18 / $11.18 / $11.30
| Professional | | $11.18 | $11.18 | $11.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.15 / $8.15 / $8.15
| Facility | | $8.15 | $8.15 | $8.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.19 / $11.19 / $11.19
| Professional | | $11.19 | $11.19 | $11.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.43 / $20.43 / $20.43
| Professional | | $20.43 | $20.43 | $20.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.30 / $13.42 / $15.66
| Professional | | $12.30 | $13.42 | $15.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.19 / $16.79 / $16.79
| Professional | | $11.19 | $16.79 | $16.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.54 / $8.82 / $16.93
| Professional | | $4.54 | $8.82 | $16.93 |