- 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
- $5.30 / $8.64 / $8.64
| Professional | | $5.30 | $8.64 | $8.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.75 / $14.17 / $16.57
| Professional | | $10.75 | $14.17 | $16.57 |
- 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 / $12.83
| Professional | | $3.02 | $8.64 | $12.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.06 / $12.00 / $16.61
| Professional | | $8.06 | $12.00 | $16.61 |