- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.78 / $6.55 / $8.40
| Facility | | $5.78 | $6.55 | $8.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.75 / $2.75 / $2.75
| Professional | | $2.75 | $2.75 | $2.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.96 / $8.40 / $8.40
| Professional | | $1.96 | $8.40 | $8.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.09 / $6.22 / $7.33
| Professional | | $5.09 | $6.22 | $7.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $8.40 / $10.50
| Professional | | $7.00 | $8.40 | $10.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.31 / $8.40 / $10.50
| Professional | | $3.31 | $8.40 | $10.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.64 / $5.46 / $10.29
| Professional | | $3.64 | $5.46 | $10.29 |