- 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
- $4.24 / $4.24 / $4.24
| Professional | | $4.24 | $4.24 | $4.24 |
- 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
- $4.24 / $4.24 / $4.24
| Professional | | $4.24 | $4.24 | $4.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.02 / $6.02 / $6.02
| Professional | | $6.02 | $6.02 | $6.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.66 / $5.09 / $5.94
| Professional | | $4.66 | $5.09 | $5.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.24 / $4.95 / $6.36
| Professional | | $4.24 | $4.95 | $6.36 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.38 / $4.05 / $4.99
| Professional | | $3.38 | $4.05 | $4.99 |