- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.26 / $14.26 / $14.26
| Facility | | $14.26 | $14.26 | $14.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.88 / $7.88 / $8.67
| Professional | | $7.88 | $7.88 | $8.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.25 / $14.25 / $14.25
| Facility | | $14.25 | $14.25 | $14.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.88 / $7.88 / $9.58
| Professional | | $7.88 | $7.88 | $9.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.94 / $9.94 / $9.94
| Professional | | $9.94 | $9.94 | $9.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.88 / $9.46 / $11.82
| Professional | | $7.88 | $9.46 | $11.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.88 / $8.14 / $11.82
| Professional | | $7.88 | $8.14 | $11.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.01 / $9.66 / $14.78
| Professional | | $7.01 | $9.66 | $14.78 |