- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.10 / $14.10 / $14.10
| Facility | | $14.10 | $14.10 | $14.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.76 / $5.76 / $5.76
| Professional | | $5.76 | $5.76 | $5.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.80 / $12.80 / $12.80
| Facility | | $12.80 | $12.80 | $12.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.77 / $5.77 / $5.77
| Professional | | $5.77 | $5.77 | $5.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.01 / $9.01 / $9.01
| Professional | | $9.01 | $9.01 | $9.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.35 / $6.93 / $8.08
| Professional | | $6.35 | $6.93 | $8.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.77 / $7.41 / $8.66
| Professional | | $5.77 | $7.41 | $8.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.02 / $8.02 / $16.27
| Professional | | $6.02 | $8.02 | $16.27 |