- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.23 / $4.80 / $6.16
| Facility | | $4.23 | $4.80 | $6.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.94 / $6.16 / $6.16
| Professional | | $2.94 | $6.16 | $6.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.13 / $8.08 / $9.44
| Professional | | $6.13 | $8.08 | $9.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.13 / $6.16 / $7.70
| Professional | | $5.13 | $6.16 | $7.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.15 / $6.16 / $7.70
| Professional | | $2.15 | $6.16 | $7.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.51 / $6.93 / $9.71
| Professional | | $5.51 | $6.93 | $9.71 |