- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.16 / $4.71 / $6.05
| Facility | | $4.16 | $4.71 | $6.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.68 / $6.05 / $22.00
| Professional | | $3.68 | $6.05 | $22.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.54 / $6.05 / $6.05
| Professional | | $2.54 | $6.05 | $6.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.14 / $6.78 / $7.93
| Professional | | $5.14 | $6.78 | $7.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.04 / $6.05 / $7.56
| Professional | | $5.04 | $6.05 | $7.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $6.05 / $7.56
| Professional | | $3.02 | $6.05 | $7.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.65 / $6.29 / $8.82
| Professional | | $4.65 | $6.29 | $8.82 |