- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.74 / $5.68 / $6.89
| Facility | | $4.74 | $5.68 | $6.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.25 / $5.22 / $6.89
| Professional | | $4.25 | $5.22 | $6.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.51 / $4.51 / $4.51
| Professional | | $4.51 | $4.51 | $4.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.38 / $12.37 / $14.47
| Professional | | $9.38 | $12.37 | $14.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.74 / $6.89 / $8.61
| Professional | | $5.74 | $6.89 | $8.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.41 / $6.89 / $11.16
| Professional | | $2.41 | $6.89 | $11.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.75 / $9.94 / $11.42
| Professional | | $8.75 | $9.94 | $11.42 |