- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.21 / $4.76 / $6.12
| Facility | | $4.21 | $4.76 | $6.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.59 / $4.59 / $4.59
| Professional | | $4.59 | $4.59 | $4.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.12 / $6.12 / $6.12
| Professional | | $4.12 | $6.12 | $6.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.28 / $10.94 / $12.75
| Professional | | $8.28 | $10.94 | $12.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.09 / $6.12 / $7.65
| Professional | | $5.09 | $6.12 | $7.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.14 / $6.12 / $9.88
| Professional | | $2.14 | $6.12 | $9.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.71 / $9.24 / $12.80
| Professional | | $5.71 | $9.24 | $12.80 |