- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.98 / $6.98 / $6.98
| Facility | | $6.98 | $6.98 | $6.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.18 / $4.18 / $5.52
| Professional | | $4.18 | $4.18 | $5.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.09 / $4.09 / $4.09
| Professional | | $4.09 | $4.09 | $4.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.72 / $5.72 / $5.72
| Professional | | $5.72 | $5.72 | $5.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.42 / $4.82 / $5.63
| Professional | | $4.42 | $4.82 | $5.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.01 / $4.70 / $6.03
| Professional | | $4.01 | $4.70 | $6.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.68 / $4.59 / $5.05
| Professional | | $3.68 | $4.59 | $5.05 |