- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.94 / $6.73 / $8.64
| Facility | | $5.94 | $6.73 | $8.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.89 / $8.64 / $8.64
| Professional | | $5.89 | $8.64 | $8.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.20 / $16.10 / $18.84
| Professional | | $12.20 | $16.10 | $18.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.20 / $8.64 / $10.80
| Professional | | $7.20 | $8.64 | $10.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $8.64 / $14.58
| Professional | | $3.02 | $8.64 | $14.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.06 / $13.64 / $18.88
| Professional | | $8.06 | $13.64 | $18.88 |