- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.28 / $6.28 / $6.28
| Facility | | $6.28 | $6.28 | $6.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.99 / $3.99 / $3.99
| Professional | | $3.99 | $3.99 | $3.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.27 / $6.27 / $6.27
| Facility | | $6.27 | $6.27 | $6.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.95 / $3.95 / $3.95
| Professional | | $3.95 | $3.95 | $3.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.18 / $5.18 / $5.18
| Professional | | $5.18 | $5.18 | $5.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.34 / $4.74 / $5.54
| Professional | | $4.34 | $4.74 | $5.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.95 / $4.26 / $5.93
| Professional | | $3.95 | $4.26 | $5.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.60 / $3.26 / $4.30
| Professional | | $1.60 | $3.26 | $4.30 |