- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.80 / $5.44 / $6.98
| Facility | | $4.80 | $5.44 | $6.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.34 / $6.98 / $6.98
| Professional | | $3.34 | $6.98 | $6.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.98 / $9.19 / $10.77
| Professional | | $6.98 | $9.19 | $10.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.82 / $6.98 / $8.73
| Professional | | $5.82 | $6.98 | $8.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.99 / $6.98 / $8.31
| Professional | | $5.99 | $6.98 | $8.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.29 / $7.88 / $11.08
| Professional | | $6.29 | $7.88 | $11.08 |