- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.75 / $6.61 / $6.92
| Facility | | $5.75 | $6.61 | $6.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $6.03 / $8.32
| Professional | | $3.02 | $6.03 | $8.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $5.50 / $5.50
| Professional | | $5.50 | $5.50 | $5.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $15.49 / $17.38
| Professional | | $12.02 | $15.49 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $8.32 / $10.47
| Professional | | $7.08 | $8.32 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.95 / $9.77 / $13.49
| Professional | | $2.95 | $9.77 | $13.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.23 / $12.88 / $17.78
| Professional | | $10.23 | $12.88 | $17.78 |