- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.38 / $8.38 / $8.38
| Facility | | $8.38 | $8.38 | $8.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.60 / $3.60 / $3.60
| Professional | | $3.60 | $3.60 | $3.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.36 / $8.36 / $8.36
| Facility | | $8.36 | $8.36 | $8.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.57 / $3.57 / $3.57
| Professional | | $3.57 | $3.57 | $3.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.34 / $4.34 / $4.34
| Professional | | $4.34 | $4.34 | $4.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.93 / $4.29 / $5.00
| Professional | | $3.93 | $4.29 | $5.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.57 / $3.57 / $5.36
| Professional | | $3.57 | $3.57 | $5.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.23 / $4.17 / $43.25
| Professional | | $3.23 | $4.17 | $43.25 |