- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.50 / $6.61 / $7.94
| Facility | | $5.50 | $6.61 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $6.03 / $6.61
| Professional | | $3.98 | $6.03 | $6.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $5.25 / $7.94
| Professional | | $5.25 | $5.25 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.48 / $14.79 / $16.22
| Professional | | $11.48 | $14.79 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.61 / $7.94 / $10.00
| Professional | | $6.61 | $7.94 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $9.33 / $12.88
| Professional | | $2.75 | $9.33 | $12.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.61 / $12.02 / $16.60
| Professional | | $6.61 | $12.02 | $16.60 |