- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.92 / $4.44 / $5.70
| Facility | | $3.92 | $4.44 | $5.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.73 / $5.70 / $5.70
| Professional | | $3.73 | $5.70 | $5.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.73 / $10.19 / $11.95
| Professional | | $7.73 | $10.19 | $11.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.75 / $5.70 / $7.13
| Professional | | $4.75 | $5.70 | $7.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.70 / $5.70 / $7.13
| Professional | | $5.70 | $5.70 | $7.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.32 / $8.63 / $11.95
| Professional | | $5.32 | $8.63 | $11.95 |