- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.65 / $6.40 / $8.22
| Facility | | $5.65 | $6.40 | $8.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $8.22 / $8.22
| Professional | | $5.50 | $8.22 | $8.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.17 / $14.74 / $17.23
| Professional | | $11.17 | $14.74 | $17.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.85 / $8.22 / $10.28
| Professional | | $6.85 | $8.22 | $10.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.88 / $8.22 / $13.28
| Professional | | $2.88 | $8.22 | $13.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.67 / $12.36 / $17.23
| Professional | | $7.67 | $12.36 | $17.23 |