- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.90 / $13.90 / $13.90
| Facility | | $13.90 | $13.90 | $13.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.89 / $7.89 / $8.67
| Professional | | $7.89 | $7.89 | $8.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.91 / $13.91 / $13.91
| Facility | | $13.91 | $13.91 | $13.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.88 / $7.89 / $9.27
| Professional | | $7.88 | $7.89 | $9.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.61 / $9.61 / $9.61
| Professional | | $9.61 | $9.61 | $9.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.89 / $9.46 / $11.83
| Professional | | $7.89 | $9.46 | $11.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.88 / $8.16 / $11.84
| Professional | | $7.88 | $8.16 | $11.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.06 / $8.83 / $9.96
| Professional | | $7.06 | $8.83 | $9.96 |