- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.48 / $7.48 / $7.48
| Facility | | $7.48 | $7.48 | $7.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.48 / $7.48 / $7.48
| Facility | | $7.48 | $7.48 | $7.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.23 / $4.23 / $4.23
| Professional | | $4.23 | $4.23 | $4.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.77 / $5.77 / $5.77
| Professional | | $5.77 | $5.77 | $5.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.65 / $5.07 / $5.92
| Professional | | $4.65 | $5.07 | $5.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.23 / $4.74 / $6.35
| Professional | | $4.23 | $4.74 | $6.35 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.12 / $3.99 / $4.88
| Professional | | $1.12 | $3.99 | $4.88 |