- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.54 / $5.14 / $6.60
| Facility | | $4.54 | $5.14 | $6.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.32 / $6.60 / $6.60
| Professional | | $4.32 | $6.60 | $6.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.96 / $11.81 / $13.80
| Professional | | $8.96 | $11.81 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $6.60 / $8.25
| Professional | | $5.50 | $6.60 | $8.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.60 / $8.25 / $33.00
| Professional | | $6.60 | $8.25 | $33.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.16 / $10.00 / $13.84
| Professional | | $6.16 | $10.00 | $13.84 |