- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.30 / $7.14 / $9.17
| Facility | | $6.30 | $7.14 | $9.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.89 / $9.17 / $9.17
| Professional | | $5.89 | $9.17 | $9.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $15.85 / $18.57
| Professional | | $12.02 | $15.85 | $18.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.64 / $9.17 / $11.46
| Professional | | $7.64 | $9.17 | $11.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.21 / $9.17 / $14.34
| Professional | | $3.21 | $9.17 | $14.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.56 / $13.42 / $18.57
| Professional | | $8.56 | $13.42 | $18.57 |