- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.22 / $15.22 / $15.22
| Facility | | $15.22 | $15.22 | $15.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.66 / $3.66 / $4.83
| Professional | | $3.66 | $3.66 | $4.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.22 / $15.22 / $15.22
| Facility | | $15.22 | $15.22 | $15.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.52 / $3.52 / $3.52
| Professional | | $3.52 | $3.52 | $3.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.23 / $7.23 / $7.23
| Professional | | $7.23 | $7.23 | $7.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.88 / $4.23 / $4.93
| Professional | | $3.88 | $4.23 | $4.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.52 / $5.28 / $5.94
| Professional | | $3.52 | $5.28 | $5.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.28 / $6.39 / $15.48
| Professional | | $4.28 | $6.39 | $15.48 |