- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.53 / $5.13 / $6.59
| Facility | | $4.53 | $5.13 | $6.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.23 / $4.23 / $4.23
| Professional | | $4.23 | $4.23 | $4.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.73 / $6.59 / $6.59
| Professional | | $3.73 | $6.59 | $6.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.73 / $10.19 / $11.95
| Professional | | $7.73 | $10.19 | $11.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.49 / $6.59 / $8.24
| Professional | | $5.49 | $6.59 | $8.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.31 / $6.59 / $9.22
| Professional | | $2.31 | $6.59 | $9.22 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.15 / $8.63 / $12.28
| Professional | | $6.15 | $8.63 | $12.28 |