- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.35 / $6.07 / $7.79
| Facility | | $5.35 | $6.07 | $7.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.93 / $7.79 / $7.79
| Professional | | $3.93 | $7.79 | $7.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.06 / $10.63 / $12.42
| Professional | | $8.06 | $10.63 | $12.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.49 / $7.79 / $9.74
| Professional | | $6.49 | $7.79 | $9.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.73 / $7.79 / $9.74
| Professional | | $2.73 | $7.79 | $9.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.27 / $9.13 / $12.82
| Professional | | $7.27 | $9.13 | $12.82 |