- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.17 / $4.73 / $6.07
| Facility | | $4.17 | $4.73 | $6.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.34 / $5.05 / $31.73
| Professional | | $4.34 | $5.05 | $31.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.93 / $6.07 / $6.07
| Professional | | $3.93 | $6.07 | $6.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.92 / $10.44 / $12.21
| Professional | | $7.92 | $10.44 | $12.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.05 / $6.07 / $7.59
| Professional | | $5.05 | $6.07 | $7.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.13 / $6.07 / $9.44
| Professional | | $2.13 | $6.07 | $9.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.67 / $8.83 / $12.22
| Professional | | $5.67 | $8.83 | $12.22 |